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NAVMED P-5088 




Vol. 45 



Friday, 14 May 1965 



No. 9 




CONTENTS 



FEATURE ARTICLE 



"What's New 
Vasodilators 



in the Management 
and Shock 



of Trauma"- 



MEDICAL ARTICLES 

Coronary Care Unit (1) 

Management of Underwater Accidents 

FROM THE NOTE BOOK 

29th Annual Educational Conference 

Scientific Meeting and Historical Exhibit at the U.S. 

Naval Hospital, St. Albans, New York 

Important New Appointment 

SECNAV Retention Policy Board 

10th Anniversary of the Polio Vaccine 

Acknowledgment , 

Annual Meetings 

Armed Forces Day 

Clinical Record, Ophthalmologic Consultation 

Stained Glass Window Dedicated 

DENTAL SECTION 

Effect of Partial Defluoridation of a Water Supply on 
Dental Fluorosis 



11 

13 
13 
13 
14 
14 
14 
14 
14 
14 



15 



Facial Pain 

Simplified Endodontic File and Reamer Cleaning 

Snuff Dippers' Intraoral Cancer: Clinical Character- 
istics and Response to Therapy 

Personnel and Professional Notes 



OCCUPATIONAL MEDICINE 

Orthopedic Evaluation of Employee for Considera- 
tion of Employment in Heavy Industry 

A Report on Protection of Longshoremen From 
Chemical Spills 

Hazards of Alloys and Semimetallics of the Ferro- 
alloy Industry 

MISCELLANY 

Joint Meeting Between Brooklyn Surgical' Society and 
Staff of the U.S. Naval Hospital, St. Albans, New 
York 

SAB, Board of Governors Meet at AFIP 

Directory of Poison Control Centers 

Construction Grants Awarded 

1943 Wave Recruit Recalls 22 Years Service with the 

Navy 

Anniversary Greetings to Nurse Corps Officers 

To the Officers of the Navy Nurse Corps 



15 
16 

16 
17 



19 

22 



24 



25 
25 
26 
26 

26 
28 
29 



United States Navy 

MEDICAL NEWS LETTER 

Friday, 14 May 1965 

Rear Admiral Robert B. Brown MC USN 
Surgeon General 

Rear Admiral R. O. Canada MC USN 
Deputy Surgeon General 

Captain F. R. Petiprin MSC USN, Editor 

William A. Kline, Managing Editor 

Contributing Editors 

Aviation Medicine Captain C. E. Wilbur MC USN 

Dental Section Captain C. A. Ostrom DC USN 

Occupational Medicine CDR N. E. Rosenwinkel MC USN 

Preventive Medicine Captain J. W. Millar MC USN 

Radiation Medicine Captain J. H. Schulte MC USN 

Reserve Section Captain C. Cummings MC USNR 

Submarine Medicine Captain J. H. Schulte MC USN 



Vol. 45 



No. 9 



Policy 
The U.S. Navy Medical News Letter is basically an 
official Medical Department publication inviting the 
attention of officers of the Medical Department of the 
Regular Navy and Naval Reserve to timely up-to-date 
items of official and professional interest relative to 
medicine, dentistry, and allied sciences. The amount 
of information used is only that necessary to inform 
adequately officers of the Medical Department of the 
existence and source of such information. The items 
used are neither intended to be, nor are they, sus- 



ceptible to use by any officer as a substitute for any 
item or article in its original form. All readers of the 
News Letter are urged to obtain the original of those 
items of particular interest to the individual. 

Change of Address 

Please forward changes of address for the News Letter 
to: Commanding Officer, U.S. Naval Medical School, 
National Naval Medical Center, Bethesda, Maryland 
20014, giving full name, rank, corps, and old and new 

addresses. 



FRONT COVER: The U.S. Naval Hospital, Guantanamo Bay, Cuba had its origin as a small dispensary in 1903 
when as an outcome of the Spanish-American War, the United States acquired the use of the Bay and surrounding 
land area for a coaling station. 

With the gradual evolution of the station to a Naval Base, the medical facilities were expanded and moved to 
Administration Hill. 

After reaching a bed capacity of 150 the dispensary status was changed and the U.S. Naval Hospital, Guantanamo 
Bay, Cuba, was commissioned on 1 June 1946. 

Because of the fire hazard, excessive maintenance costs, and deteriorating condition of the many small wooden 
frame buildings it was found necessary to construct a new hospital to meet the needs of the fleet and base popula- 
tion. 

In 1954 Congress authorized construction of a 100 bed hospital with additional quarters for nurses and barracks 
for corpsmen. Following ground-breaking ceremonies on 11 January 1955 construction was completed and dedica- 
tion ceremonies were held on 24 September 1956. 

Built of reinforced concrete, this was the first naval hospital to be fully air conditioned. Its modern architecture 
and its location on a 13 acre bluff overlooking the bay make it one of our most attractive naval hospitals. 

The issuance of this publication approved by the Secretary of the Navy on 4 May 1964. 

U.S. NAVY MEDICAL NEWS LETTER 



FEATURE ARTICLE 

"WHAT'S NEW IN THE MANAGEMENT OF TRAUMA" 

VASODILATORS AND SHOCK 

Dean H. Morrow, MD, Department of Anesthesiology, 
University of Kentucky Medical Center, Lexington, Kentucky 



The clinical manifestations of shock have been 
familiar to physicians for over 100 years, and during 
this period of time, continued efforts have been 
made to elucidate the basic pathophysiologic altera- 
tions associated with the shock syndrome. This work 
has been hampered by the fact that experimental and 
clinical shock can result from a variety of causes 
and that, until recently, there were few controlled 
studies of shock in man. Nevertheless, it is now gen- 
erally agreed that impaired cellular perfusion secon- 
dary to intense vasoconstriction and altered organ 
blood flow is characteristic of the shock state regard- 
less of the etiology. It seems clear, also, that the 
vasoconstriction is due, at least in part, to marked 
over-activity of the adrenergic nervous system. In 
addition, it appears probable that whether or not 
the state of shock can be reversed with appropriate 
therapy depends upon the degree of metabolic de- 
rangement which has been produced by the impaired 
cellular perfusion. 

As pointed out in a recent review, 1 many investi- 
gators have observed that when active vasoconstric- 
tion was blocked there was a significant increase 
in the survival of experimental animals subjected to 
shock. The protection afforded by limiting vasocon- 
striction was found to be similar whether the animals 
were subjected to hemorrhagic, traumatic or endo- 
toxin shock. Further, the degree of shock protection 
was similar whether the sympathetic block was pro- 
duced by the direct acting vasodilator drugs, sym- 
pathectomy, or adrenergic and ganglionic blockade. 
It was significant, also, that the protection afforded 
by the various adrenergic-blocking techniques em- 
ployed did not seem to be of value in acute hemor- 
rhage or trauma. In these "acute conditions" the only 
therapy required was prompt replacement of the vol- 



ume deficit of blood and other fluid. Although little 
is known about the precise physiologic mechanisms 
by which adrenergic blockade alters the course of 
shock, it has been suggested by Nickerson that two 
important effects are most likely involved. These 
effects are an alteration of fluid exchange between 
the intravascular and extracellular compartments 
and a redistribution of local blood flow. Support 
for such effects are found in the observations that 
blockade of vasomotor activity has been shown to 
be followed by a prompt rise in plasma volume, 
and prevents the shift of blood to metabolically less 
active areas, such as the splanchnic bed during the 
development of shock 1 . Although these experimental 
concepts have yet to be completely clarified and 
quantitative in patients, they have served as a basis 
for the limited application of adrenergic blockade 
in the treatment of clinical shock of varying etiolo- 
gies 1 . In addition, they have prompted an evaluation 
of the possible benefits of sympathetic blockade of 
surgical patients in which reduced tissue perfusion 
was anticipated 3 . 

The sympatholytic effects of two types of drugs 
have received the most widespread clinical applica- 
tion in shock. These are phenoxybenzamine (Diben- 
zyline), and the adrenal steroids. Of the adrenal 
steroids, hydrocortisone (Solu-Cortef) has been 
used most extensively. Each of these drugs has been 
used as an adjunct to the treatment of established 
shock which had not responded to the administration 
of blood or blood substitutes. Phenoxybenzamine 
was used in a maximal dose of 1.0 mg./Kg, admin- 
istered intravenously at a rate slow enough so as 
not to produce an abrupt fall in the systemic ar- 
terial pressure. The time required to administer the 
total dose of drug was as long as 24 hours 1, z . The 



U.S. NAVY MEDICAL NEWS LETTER 



1 



dose of hydrocortisone utilized was 15-25 mg./Kg, 
administered intravenously during the first 24 hours 
of treatment. The incidence of further hypotension 
with hydrocortisone has been reported as being mini- 
mal 3 . One drug, phenoxybenzamine, has received 
limited use in the pretreatment of surgical patients 
undergoing corrective cardiac operations utilizing 
extracorporeal circulation. Doses ranging between 
0.5 and 1.0 mg./Kg have been administered intra- 
venously in order to induce a sympathetic block prior 
to the start of cardiopulmonary bypass 3 . 

In each of these clinical circumstances the anti- 
adrenergic drug was administered only after a critical 
evaluation of the patient's blood volume and appro- 
priate replacement of blood and/or intravenous 
fluid. In every patient in which either phenoxybenz- 
amine or hydrocortisone was used there were contin- 
uous measurements of the systemic arterial and ve- 
nous pressures in addition to careful evaluation of 
the urinary output and blood electrolyte alterations. 

As the result of his experience using phenoxybenz- 
amine in the treatment of human shock,-' 4 Nicker- 
son has reported the following conclusions: 1 . Rapid 
and adequate circulatory volume replacement was 
the only therapy required in most cases of early 
shock; 2. The rapidity and magnitude of the hypo- 
tensive response to the blocking agent was a reliable 
indication of the adequacy of the circulating blood 
volume, and the volume of fluid required to restore 
blood pressure gives a semiquantitative measure of 
any deficit; 3. Low blood pressure values were well 
tolerated providing vasoconstriction was prevented 
and adequate venous return maintained; 4. Severe 
shock can occur at normal or elevated blood pres- 
sures; 5. Some individuals who failed to show a sus- 
tained improvement following one or more large 
transfusions were observed to do so after the block- 
ing agent was administered; 6. In patients with in- 
adequate myocardial function the administration of 
phenoxybenzamine permitted an increase in the rate 
of administration and in the total volume of fluid 
which could be tolerated without pulmonary con- 
gestion; 7. In many patients an improved level of 



renal function parallel to the improved cardiovascu- 
lar status was observed following adrenergic block- 
ade; 8. In prolonged shock, the incidence of an im- 
proved renal response was less than the incidence 
of cardiovascular improvement; 9. There was no in- 
dication for anti-adrenergic blockade in hypotensive 
patients who do not exhibit clinical signs of peripher- 
al vasoconstricton and an increased level of sym- 
pathetic nervous system tone; and 10. There were 
no obvious differences noted between the responses 
of patients in shock due to hemorrhage, trauma or 
infection or between groups which were in shock 
for varying periods of time. Lillehi and associates 
have reported similar beneficial results from their 
experience using the adrenal steroids as adjuncts to 
shock therapy 3 . In addition, these investigators have 
concluded from observations of surgical patients in 
which phenoxybenzamine pretreatment was used 
prior to starting bypass that: 1. The drug induced 
adrenergic blockade permits better perfusion; 2. 
Blood replacement following bypass is facilitated 
since, under these circumstances, low arterial pres- 
sure means low blood volume; and 3. The phenoxy- 
benzamine block may permit more adequate urinary 
output during bypass and during the postoperative 
period. 

It seems clear from the results of the various care- 
fully conducted experimental studies in laboratory 
animals and man that an interruption of sympathetic 
vasomotor activity may be beneficial in preventing 
cellular derangements secondary to impaired cellular 
perfusion. The effects of this type of therapy, as 
well as, a precise definition of shock in terms of 
cellular metabolism await clarification. 

Bibliography 

1. NickersDn, M. : Sympathetic Blockade in the Therapy of Shock, 
American Jour of Cardiology 12: 619, 1963. 

2. NickersDn, M. : Vasoconstriction and Vasodilatation in Shock, in 
Hershey, S.G.: Shock, International Anesthesiology Clinics, Bos- 
ton, Massachusetts, Little, Brown and Company, 1964, p. 385. 

3. Lillehei, R.C., Longerbeam, J.K., Bloeh, J.H. and Manax, W.G.: 
The Modern Treatment of Shock Based on Physiologic Principles. 
Clinical Pharmacology and Therapeutics 5: 63, 1964. 

4. Nickerson, M. : Clinical Observations on the Use of Vasodilators 
in the Treatment of Shock, in Eiseman, B. and Bosomworth, P.P.: 
Vasodilator Agents in Management of Wound Shock, Washing- 
ton, D.C., National Academy of Sciences-National Research Coun- 
cil, 1963, p. 47. 



U.S. NAVY MEDICAL NEWS LETTER 






MEDICAL ARTICLE 

CORONARY CARE UNIT (1) 
A SPECIALIZED INTENSIVE CARE UNIT FOR ACUTE MYOCARDIAL INFARCTION 



PaulN. Yu,MD* 

Professor of Medicine and Head, 

Cardiopulmonary Unit 
University of Rochester School of 

Medicine and Dentistry 
Rochester, New York 

Clarence A. Imboden, Jr., MD 
Chief, Coronary Heart Disease 

Section, Heart Disease 

Control Program 
U.S. Public Health Service 
Washington, District of Columbia 



Samuel M. Fox, HI, MD 
Deputy Chief, Heart Disease 

Control Program 
U.S. Public Health Service 
Washington, District of Columbia 



Thomas Killip, III, MD 
Associate Professor of Medicine 
Cornell University College of 

Medicine, and 
Chief, Division of Clinical Cardiology 
New York Hospital 
New York, New York 



The mortality from coronary heart disease in this 
country exceeds half a million a year, making it the 
greatest single cause of death. Despite considerable 
advances in our knowledge concerning the path- 
ophysiology and risk factors of coronary atheroscle- 
rosis and vast improvement in the diagnosis and man- 
agement of this disease, there has been, as yet, no 
effective and satisfactory program to reduce signifi- 
cantly the mortality rate. 

Need for a Coronary Care Unit 

Eighty-five per cent of the deaths from myocardial 
infarction occur within the first week of the attack. 
The vast majority of these deaths result from cardiac 
arrhythmia, cardiogenic shock, or cardiac failure, 
alone or in combination. Rapidly accumulating ex- 
perience indicates that prompt and effective treat- 
ment in the hospital will significantly reduce this 
mortality, particularly if the potentially lethal cardiac 
arrhythmias (ventricular fibrillation, tachycardia and 
asystole) are promptly detected, diagnosed, and 



From the Council on Clinical Cardiology of the American Heart 
Association, New York, New York, and the Heart Disease Control 
Program, Division of Chronic Diseases, U.S. Public Health Service, 
Washington, District of Columbia. 



treated by the application of modern techniques, as- 
sisted by a competent staff. This requires continual 
attention and instantaneous action. It is therefore 
suggested that, for the first few days, patients with 
myocardial infarction, known or suspected, be pro- 
vided with constant and intensive care in order to 
facilitate early detection of complications and 
prompt, effective treatment. 

Recent Clinical Reports 

Recent studies in several hospitals suggest that 
a Coronary Care Unit may significantly improve 
therapy and reduce mortality in this disease. Up to 
December, 1964, several groups of workers have 
reported in the literature, or in unpublished data 
available to us, various major types of cardiac ar- 
rhythmias and conduction defects observed in pa- 
tients with acute myocardial infarction by continuous 
monitoring in special coronary care areas. Although 
information is not entirely uniform or complete, the 
figures presented in table 1 show that the over-all 
incidence is approximately 70%. Furthermore, in 
one patient two or more types of cardiac arrhyth- 
mias and/or conduction defects may be observed. 



U.S. NAVY MEDICAL NEWS LETTER 







TABLE 1 








INCIDENCE OF CARDIAC ARRHYTHMIAS 


AND CONDUCTION DEFECTS IN ACUTE 


MYOCARDIAL 


INFARCTION DETECTED BY CONTINUOUS 


MONITORING 




Authors: 


Spann 


Robinson 


Julian 


Brown 


Meltzer 


Day 


Number of patients 


30 


36 


100 


100 


141 


155 


Duration of monitoring 


Up to 


Until free of 


Up to 


Up to 


72 hours 


Up to 




four days 


chest pain 
for 72 hours 


five days, 
or longer 


two weeks 




12 days 


Incidence of all types of 


73 


75 


95 


61 


71 


60 


arrhythmias (% ) 














Major types* 














1. Atrial or supraventricular 


I 


2 


4 




12 




tachycardia 










3 




2. Atrial nutter 




1 


2 






3. Atrial fibrillation 


3 


5 


16 


10 


12 


15 


4. Multiple ventricular 


9 


12 


67 


40 


40 




premature beats 














5. Ventricular tachycardia 


11 


3 


6 


11 


19 


14 
11 


6. Ventricular fibrillation 




3 


10 




6 


7. Ventricular asystole 




7 






4 


10 


8. 1° or 2° A-V block 


2 


12 


23 




19 




9. Complete A-V block 






8 




8 


4 


10. Bundle-branch block 


5 




13 




31 


11 



Patients who had more than one major type of cardiac arrhythmia were also included for analysis. 



Nevertheless, it is apparent that continuous monitor- 
ing may uncover important cardiac arrhythmias 
which would otherwise escape detection, and that 
the incidence observed by these workers is consider- 
ably greater than that reported in previous studies 
of a similar nature in which no continuous monitor- 
ing was employed. This emphasizes the importance 
of early and immediate recognition of cardiac ar- 
rhythmias, making possible prompt intervention and 
treatment which may save many lives. 

Dr. Day of Bethamy Hospital, Kansas City, Kan- 
sas, and Dr. Meltzer of Presbyterian Hospital, Phila- 
delphia, Pennsylvania, have kindly transmitted to us 
for our review their latest reports in regard to the 
number, major complications, types of cardiac ar- 
rhythmias, and survival rate of the patients with acute 
myocardial infarction in their respective Coronary 
Care Units. Because of the relatively small number 
of patients studied, it is not yet feasible to submit 
the clinical data for statistical comparison. The re- 
sults so far, however, have indicated a favorable 
trend toward reduced mortality when patients with 
acute myocardial infarction are constantly observed 
and their complications promptly treated in a Coro- 
nary Care Unit. 

Organization of a Coronary Care Unit 

It should be emphasized that the following sug- 
gestions and recommendations concerning criteria 
for personnel, physical design and construction, and 



equipment are based on limited experience. Further- 
more, usefulness of information and reliability of 
equipment are subject to further study. In the future, 
some of the items mentioned may be replaced by 
superior equipment or become unnecessary. 

The establishment, performance, and success of 
a Coronary Care Unit depend upon three important 
factors: personnel requirements, physical design and 
structural needs, and instrumental equipment. 

Personnel Requirements 

The key to the successful operation of a Coronary 
Care Unit is staffing the unit with a group of spe- 
cially motivated, trained, and dedicated physicians 
and nurses who are responsible for the care of the 
patients with acute myocardial infarction. 

Unit Director: The unit should be organized un- 
der the direction of a cardiologist or a small group 
of physicians. Prior to the opening of a unit, a policy 
statement by the administrator of the hospital and 
the chairmen of the appropriate departments should 
clarify and delineate the authority of the director 
or responsible physician of the unit in determining 
policies of admission, length of stay, discharge of 
the patients, and other operational problems and 
procedures. 

Physicians: House officers (interns and assistant 
residents) may rotate through the unit for a specific 
period, and at least one physician should be on duty 
at all times. The house officers should receive contin- 



U.S. NAVY MEDICAL NEWS LETTER 



uing education and training in the newer techniques 
and knowledge of the diagnosis, prevention, and 
treatment of cardiac arrhythmias, cardiogenic shock, 
cardiac failure, and other complications which may 
occur in acute myocardial infarction. The assign- 
ment, function, and responsibility of the attending 
physician in relation to the unit may vary from one 
hospital to another, but should be definitely stated 
in writing. In some hospitals, where there are rela- 
tively few or no house officers, special arrangements 
have to be made to ensure full coverage by expe- 
rienced physicians around the clock. 

It may be advisable to set up a special committee 
on Coronary Care Units in a given hospital. This 
committee would see that the best procedures are 
used, adequate staff provided, and an educational 
program carried out for all physicians connected 
with the hospital. 

Nurses: Nurses staffing a Coronary Care Unit 
play a key role in its proper function. The nurse 
will frequently be the first professional person to 
recognize and initiate treatment for a complication, 
such as cardiac arrest. The selection of nursing staff 
should be based upon skills, interest, motivation, and 
intiative. However, opportunity should be provided 
for other nurses in the hospital to rotate periodically 
through the unit. The hospital should attempt to 
provide special recognition for the nurses working 
in this unit, possibly including higher salaries and 
more free time than are customary for less demand- 
ing services. A program of continuing education 
should be instituted and encouraged. A special 
course of instruction should be given for all nurses 
working in the unit. The course should encompass 
at least the following: 

1 . Instruction in anatomy, physiology, and pathol- 
ogy related to coronary heart disease. 

2. Clinical features and complications of acute 
myocardial infarction. 

3. Electrocardiography, especially the pattern re- 
cognition of cardiac arrhythmias. 

4. Fundamentals, operation, and limitation of 
electronic equipment. 

5. Special care of patients in Coronary Care 
Units. 

6. Principles and practice of cardiac resuscitation, 
including use of pacemakers and defibrillation, and 
depending on local policies and immediate availabil- 
ity of experienced physicians. 

Physical Design and Structural Needs 

In order to achieve constant and intensive obser- 
vation of patients with acute myocardial infarction 



and to provide immediate emergency treatment po- 
tentially lethal complications, the following criteria 
of physical design and facilities of the Coronary 
Care Unit should be taken into consideration: 

Physical Design 

1. The unit should be established as a separate 
area within a hospital and situated as near the emer- 
gency department or a general medical ward as pos- 
sible. Adequate transportation facilities for rapid 
mobilization of proper personnel and equipment 
must be provided. 

2. The functional or structural form of a unit may 
be a circle, semicircle, or tangential variant (hexa- 
gon or octagon) with fixed, movable, orcurtain parti- 
tions, and relative privacy for each patient. It should 
provide an attractive and noninstitutional atmosphere 
for both professional staff and patients. Special 
provisions should be made for the removal of de- 
ceased patients with minimal disturbance and 
inconvenience. 

3. The unit should be constructed so that direct 
observation of all patients is possible from a central 
nursing station and working area. The distance from 
the nursing station to the patients' beds should be 
relatively short; an adequate open area should be 
provided for equipment in the nursing station, Nurs- 
ing care is facilitated if the alarm signals and moni- 
tors are placed so as to provide maximum audio- 
visual contact for staff while they are working in 
patient rooms, as well as at the desk. 

4. The minimal floor space for a five-bed unit 
is estimated to be approximately 1,100 square feet. 
This includes separate patient areas, nursing station, 
storage space for equipment and medicine, utility 
rooms, and toilets. For each individual patient, an 
enclosed space of approximately 132 square feet (12 
x 11 ) should be the minimum size. Adequate space 
around the patients' beds is essential to provide easy 
access, and movement of extra personnel and 
equipment. 

5. Additional rooms adjacent to the unit should 
be provided for physicians' consultations, sleeping 
area, and nurses' lounge. It has been suggested that 
a family room should be situated at some distance 
from the unit in order to avoid unnecessary interfer- 
ence and visits. At least two chairs for each coronary 
bed seem desirable. 

Structural needs 

It is suggested that the following items be consid- 
ered and included as prerequisites in construction: 

1. Electrical isolation to minimize the problem 
of interference in electronic monitoring. 



U.S. NAVY MEDICAL NEWS LETTER 



2. Sound-proof structure with acoustical tile ceil- 
ing and conductive floor tiles laid over grounded 
copper. 

3. Adequate lighting for routine and emergency 
examination (two 300-watt lights — one spot and one 
flood — at the head of each bed) . 

4. Proper air-conditioning to control temperature 
and humidity. 

5. Well-planned intercommunication, signal, and 
alarm systems, including: 

Patients to nurses' station. 

Nurses' station to family waiting room, nurses' 

lounge and physicians' room. 
Nurses' station to page operator, or linking to 

page system. 
Central alarm button at nurses' desk to alert 
appropriate physicians. 
It should be emphasized that monitoring is useless 
unless there are good communication and signal 
systems in the unit. 



6. Adequate electrical circuits (including appro- 
priate redundancy) with a number of duplex 
110-volt receptacles for monitoring and connecting 
equipment and one or two 220-volt wall receptacles 
for portable X-ray and other high-voltage equip- 
ment. Grounding of circuits, especially in older 
buildings, should be thoroughly checked by electrical ■ 
engineers. 

7. Built-in equipment, carefully planned and in- 
stalled; an adequate number of conduits to provide 
sufficient space for future additions to monitoring. 

8. Bedside outlets for oxygen and suction; wall- 
bracket support. 

9. Ceiling support with track and arm for intra- 
venous therapy. 

1 0. Night light at entrance to each room. 

1 1 . Locked medicine cabinets and dispensing shelf. 

12. Adjustable hospital bed. 

13. Any transformer for special equipment placed 
as remotely from the unit as possible. 



MANAGEMENT OF UNDERWATER ACCIDENTS 

John B. Weeth, M.D. 



The growing popularity of underwater swimming 
has brought with it an increasing incidence of under- 
water accidents. Any physician who lives near water 
more than 30 feet deep may be suddenly faced with 
the problem of diagnosis and management of an un- 
derwater accident. Injuries from spear-guns or pro- 
peller blades present no diagnostic problem. Similar- 
ly, most physicians have no difficulty recognizing and 
using appropriate medications to counteract fish poi- 
sons and stings. The enigma for many physicians 
is the patient whose injury is related to gas or pres- 
sure phenomenon, popularly known as "the bends." 
Despite a number of excellent reviews of underwater 
swimming accidents, some with outstanding illustra- 
tions, 1 " 6 including the authoritative and comprehen- 
sive US Navy Diving Manual, 7 most physicians are 
not familiar with the management of these casualties. 
It seems desirable, therefore, to review the manage- 
ment of underwater accidents and to cite illustrative 
cases. 

Drowning is still the major cause of deaths from 
underwater accidents. Butterfield and associates 8 
reported that in nine of 15 reported diving deaths 
in Massachusetts the victim perished on the surface 

From the Division of Research, Alton Ochsner Medical Foundation, 
and the Department of Medicine, Ochsner Clinic, New Orleans. 

Reprint requests to 1520 Jefferson Highway, New Orleans 70120 
<Dr. Weeth). 



after the face mask either had filled with water or 
was lost. Taylor and coauthors 9 reported that 14 
of 24 deaths in Florida could have been prevented 
by safety lines and proper use. These are sad re- 
minders that the diver's life depends on knowledge 
and training and that the physician's treatment for 
underwater accidents is to a great extent preventive. 

Both physicians and laymen who have any re- 
sponsibility for underwater swimmers should acquire 
a copy of the US Navy Diving Manual. It contains 
all the information and diving tables that are re- 
quired, is easy to read, and covers both principals 
and practice. Its military and medical tone impress 
both the novice and the self-styled expert with the 
serious implications of swimming and diving. 

The physician who sees a patient thought to be 
a victim of the bends should consider five general 
possibilities: (1) suction and blast injuries, (2) gas- 
expansion injuries, (3) decompression sickness 
(gas bubbles), (4) gas-poisoning residuals, and (5) 
emotional reactions (panic, etc.). 

Underwater Accidents 

Suction and Blast Injuries. Underwater suction in- 
jury is called "squeeze" and results from inequality 
of pressure. We all experience a mild type of squeeze 



U.S. NAVY MEDICAL NEWS LETTER 



on our eardrums when riding in an elevator if we 
have a momentary failure to equalize middle-ear 
pressure. Pressure changes in water are much greater 
in magnitude, equaling about 1 lb/sq in of added 
pressure for every 2Vi-foot descent. Thus, middle-ear 
pressure must be equalized rapidly during any de- 
scent or there will be massive hemorrhage in the 
middle ear to flood the compartment and equalize 
pressures by hydraulic means. The physician exam- 
ining the ear can see the hematoma behind the 
drum. 

Case I. — A 35-year-old diver was pulled by the 
current from a pipe to which he was clinging and 
fell rapidly from a depth of 65 to 80 feet. He was 
unable to clear one ear, and a massive hemorrhage 
in the middle ear and rupture of the eardrum 
resulted. 

Most of these injuries heal well, but they are po- 
tentially lethal. Should injury of flooding result in 
enough vestibular stimulation to cause vomiting in 
a face mask or whirling loss of orientation, drowning 
is possible. 

Hemoptysis and pulmonary edema may occur in 
a second squeeze situation. If a surface diver de- 
scends too deeply, fluid and blood may be squeezed 
from his lungs if his surface lung volume is com- 
pressed below his residual air volume. Faulty breath- 
ing regulators with extremely high inspiratory resis- 
tance may create a pulmonary intermittent suction 
situation as the diver tries to suck air. Linaweaver 10 
observed patchy pulmonary infiltrates from this 
cause in some patients. 

A serious type of squeeze may occur when using 
a face mask, helmet, or suit being supplied with 
air from the surface. Should the air hose blow loose 
or pressure fail suddenly, and the mask is not 
equipped with a properly working nonreturn valve, 
the face mask or helmet will instantly be converted 
into a giant suction cup and pull the face of the 
diver up into it. 

Case 2. — A hose blew off the surface supply tank 
while a diver was working at a depth of 50 feet. 
The nonreturn valve on his face mask failed to func- 
tion. He instantly lost pressure from his face mask 
and was unable to rip it off. Massive bruising of 
the facial tissues resulted. Fortunately, despite in- 
tense scleral hemorrhages, the vital structures and 
integrity of the eyes were preserved, and he recov- 
ered without permanent residual injury. 

If a diving suit is worn, folds of skin may be 
forced into the creases, resulting in serpentine ridges 
of bruising. If confused with cutaneous manifesta- 



tions of the bends, unnecessary treatment could 
result. 

To treat underwater blast casualties the physician 
must understand the mechanism of injury. The force 
of any blast will be transmitted through solid and 
liquid media and is diminished only by the distance. 
A blast force can obviously cause concussion of the 
brain or injury to the eardrum. Less obvious, but 
life-threatening, is the fact that as a sufficiently 
strong explosive force crosses a solid or liquid-to-gas 
interface, there is a shredding effect into the area 
of the gas. The familiar water spray shooting into 
the air from the depth charge is a classic illustration 
of this effect. Therefore, in blast victims one must 
look for pulmonary and gastrointestinal hemorrhage 
and rupture of abdominal hollow viscera. The pa- 
tient should be observed carefully for a sufficient 
period of time to ensure that significant pulmonary 
or visceral injury has not occurred. 

Case 3. — A 29-year-old diver was working in 105 
feet of water using a cutting torch. Ignition of weld- 
ing and marsh gases in a pipe resulted in an explo- 
sion which reportedly knocked dishes off shelves on 
the oil rig above. The patient received adequate 
decompression on the surface to forestall develop- 
ment of bends before being brought to Ochsner 
Foundation Hospital, New Orleans. On admission, 
both eardrums were hemorrhagic and there was 
drainage from the left ear. No abnormalities were 
detected on roentgenography of the chest and there 
were no indications of free air under the diaphragm. 
The hemoglobin level was 15 gm/100 ml and the 
white blood cell count was 17,850/cu mm with a 
shift to the left. The patient coughed frequently and 
had temperature spikes to 102 F (38.9 C during 
the first two days. By the fifth hospital day fever 
had subsided and the patient was discharged for 
outpatient observation, 

Gas-Expansion Injuries. The second type of injury 
is caused by the large volume expansion of gases 
during ascent of depressurization. Air embolism, 
which is usually fatal is most likely to occur when 
the victim surfaces rapidly and does not vent the 
expanding air from his lungs properly. As the 
trapped air expands, it enters the arterial circulation 
through the pulmonary veins and fatal doses of air 
go throughout the body. At least one fatal case has 
occurred recently in New Orleans. A victim of air 
embolism surfaces, gasps, and then sinks back be- 
neath the water. The accident usually occurs at the 
moment of surfacing. At necropsy, air bubbles may 
be found throughout the tissues. Should a victim 
survive the initial episode, he must be immediately 



U.S. NAVY MEDICAL NEWS LETTER 



repressurized to a 165-foot depth and treated ac- 
cording to USN treatment tables. 7 

Air in the lungs, at a depth of 33 feet, will double 
in volume by the time the subject has reached the 
surface, and therefore air equivalent to one total 
lung volume will have to be blown off in the last 
33 feet of ascent. The potential hazards in such a 
situation are obvious. Air embolism can be prevent- 
ed by thorough training and familiarity with equip- 
ment. The diver who does not have to ditch useless 
breathing gear and head for the surface in a panic 
will not be exposed to the danger of air embolism. 

Even if fatal air embolism does not occur, the 
expanding air can cause other problems. 

Case 4. — A 28-year-old diver was working in 110 
feet of water when a cable pulled his mask off. He 
made a free ascent to the surface and seemed to 
exhale the excess air reasonably well. Epigastric pain 
developed two or three minutes after surfacing. Re- 
compression in a chamber failed to relieve the pain 
significantly. He consulted the author four days later 
because of increased pain. On examination consider- 
able epigastric tenderness and splinting were appar- 
ent in a stoic individual. It was the initial impression 
that expanding air had overdistended the stomach. 
Two days later discomfort became more pronounced 
and he was admitted to Ochsner Foundation Hospital 
for observation by a surgical consulant as well. No 
evidence of perforated viscus was demonstrated 
roentgenographically. The pain subsided two days 
later and he was discharged from the hospital. 

Decompression Sickness. Decompression sickness, 
which is also known as caisson disease, is a more 
accurate term than "the bends." The latter has the 
popular connotation of any injury sustained in the 
water. Decompression sickness occurs when the div- 
er stays deep enough and long enough to force nitro- 
gen from the air into physical solution in his blood 
and body tissues so that if he surfaces too rapidly 
the nitrogen will precipitate in the tissues and vascu- 
lar bed as nitrogen bubbles. Both sufficient pressure 
and time are essential. A diver may safely stay at 
a 60-foot depth for one hour, but only half an hour 
at a 90-foot depth without having to decompress. The 
"no-decompression" intervals become even shorter 
as the depth increases. When tissue nitrogen satura- 
tion has exceeded a certain amount, the diver must 
come up slowly enough to allow the nitrogen to 
be breathed off to prevent precipitation of actual 
bubbles in the tissues and blood. Classic decompres- 
sion sickness is due to nitrogen bubbles from the air, 
but with appropriate pressure and time, decompres- 



sion sickness could occur from other gases as well. 
The exact method of bubble formation is not known, 
but carbon dioxide, muscular tension, and work are 
considered important precipitating factors for bubble 
formation. 1113 

The best treatment for bubble formation is pre- 
vention. The Navy treatment tables are internation- 
ally respected and should be followed exactly as 
written. It should be understood by the physician, 
however, that symptoms of bubble formation can 
occur in spite of seeming rigid adherence to the div- 
ing tables. Errors in measurement of depth-pressure 
ratios, failure to take into account previous repetitive 
dives, and fatigue have been the most frequent 
causes of symptoms here, even when "the tables 
have been followed exactly." 

When prevention has failed and bubbles occur, 
transport the patient to the nearest recompression 
chamber and treat him according to the Navy treat- 
ment tables. 7 Rivera" analyzed 935 cases of decom- 
pression sickness on file at the Experimental Diving 
Unit in Washington, DC, from 1946 to 1961. He 
concluded that the use of the Navy treatment tables, 
based on use of pressure greater than required for 
the relief of symptoms, is the best approach. 

These tables have two symptomatic sections. If 
the patient has "pain only," he is recompressed from 
6V2 to 1 1 hours. Use of 100% oxygen can cut treat- 
ment time down to 2Vi to 4 hours, respectively. 
For all other more "serious symptoms," 19 or 38 
hours in the recompression chamber are necessary 
and oxygen use does not diminish treatment time. 
At this hospital delay in starting treatment has made 
patients with "pain only" more resistant to treatment 
and has ultimately required use of 19- and 38-hour 
therapy outlined for those with "serious symptoms." 

In the Navy, divers are well motivated to report 
all symptoms, and less serious symptoms predomi- 
nate: local articular pain 89%, dizziness 5.3% and 
paralysis 2.3%. 7 Experience at the Ochsner Medical 
Center has been different. Articular pains are often 
ignored by commercial and sport divers if the pain 
is tolerable. The physician is called only when pain 
becomes unbearable or serious symptoms such as 
paralysis occur. It is not surprising, therefore, that 
in 33 instances of decompression sickness managed 
under the direction of the Ochsner Medical Center, 
13 men had significant central nervous system in- 
volvement. The table summarizes these cases. 

Presenting symptoms of spinal cord injury have 
ranged from obvious, complete paraplegia, through 
distinct lower extremity numbness and weakness, to 
two instances when urinary retention was the reason 



8 



U.S. NAVY MEDICAL NEWS LETTER 



the diver came to the doctor. Inadequate or impro- 
vised therapy was given in four cases of spinal in- 
volvement, because the divers failed to recognize the 
serious involvement until it was too late. The mid- 
thoracic and sacral spinal cord seem particularly sus- 
ceptible to permanent damage from even brief ische- 
mia and other injuring factors which may be present 
from the bubbles of decompression sickness. Thus, 
even immediate recompression treatment is not al- 
ways completely successful. Eight of nine men with 
initial spinal-cord involvement have incapacitating 
residual damage, including one permanent total par- 
aplegia. Another of these men had a convlusion 
six months after the accident, in addition to the resid- 
ual spinal-cord damage. Even delayed therapy may 
succeed, however, since the one complete recovery 
followed use of one of the Navy diving tables when 
spinal injury symptoms had been present for about 
24 hours. 

Serious initial brain involvement has had a better 
prognosis with two spontaneous recoveries. Each 
patient arrived at the Ochsner Medical Center by 
helicopter about three hours after their accident, and 
only faint residual neurological abnormalities were 
still detectable and these disappeared rapidly. 

An important problem in recompression therapy 
has been the air temperature rise during the com- 
pression phase. All of the chambers used here have 
been outdoors. Temperatures of 110 F with 100% 
humidity have been recorded at the end of slow 
compression runs. With larger, faster compressors the 
initial temperature is certainly higher. Excessive tem- 
perature is an important consideration in elective 
treatment with high-pressure oxygen, and was the 
deciding factor in not treating a patient critically 
ill with tetanus. 

Supportive therapy during recompression treat- 
ment must include copious fluids to replace the tre- 
mendous body losses of perspiration. Sedatives such 
as barbiturates, in doses of 0.1 gm every four hours, 
are occasionally necessary for the patient who be- 
comes fretful and apprehensive, particularly in the 
later stages of the 19- and 3 8 -hour therapies. Nar- 
cosis should be avoided as the patient's subjective 
responses and reflexes are the guides to length of 
recompression therapy. 

Case 5. — A 25-year-old sport diver, spear fishing 
in competition, made an uncounted number of dives, 
going as deep as 140 feet. Within 15 minutes of 
surfacing from his last dive he experienced severe 
multiple articular pains and collapse. On arrival by 
helicopter at Ochsner Foundation Hospital he was 
ashen grey; the pulse was weak and thready, the rate 



120 beats per minute. He was able to answer ques- 
tions, but often interrupted to cry out with pain, 
He had no obvious respiratory or neurological diffi- 
culties. Nail-bed cyanosis was pronounced. It was 
necessary to fly another 55 minutes in the helicopter 
to reach a compression chamber on that particular 
day. Minimum safe helicopter altitude was used and 
no harmful effects of the flight were noted on the 
patient. During the compression run, the patient lost 
detectable vital signs and respirations became evi- 
dent again only when the chamber was cooled by 
drenching it with hoses and releasing some of the 
pressure. He regained consciousness shortly and re- 
vived rapidly with oral fluids, with ultimate complete 
recovery. 

This particular case presents the common compli- 
cations of distance. Accidents treated by the Ochsner 
Medical Center occur as a result of the expansion 
of the petroleum industry into 85- to 240-foot 
depths of the Gulf of Mexico. Commercial and sport 
divers operate from or near these rigs which are 
100 to 200 miles away from the Center. This diffi- 
culty has been managed by having the physician stay 
here in New Orleans until the facts of the injury 
are fully ascertained and directing the initial phases 
of therapy at long distance. This minimizes the pos- 
sible catastrophic effects of delay in recompression 
treatment. 

Arrangements are simultaneously made for the 
physician to travel to the patient. The physician 
should go if he possibly can, to be sure that the 
diagnosis is correct and that the treatment is pro- 
ceeding properly. In three instances, on arrival at 
the accident scene, it was necessary to catheterize 
spinal-injured divers who were in considerable pain 
with urinary retention and still had more than 24 
hours of recompression therapy to endure. In anoth- 
er instance, a convulsion had occurred while the 
physician was en route. Examination in the chamber 
confirmed that no associated injury or disease was 
present, which required altering the plan of 
treatment. 

The physician should be prepared to enter the 
chamber, but must remember that he is exposing 
himself to possible ear squeeze, nitrogen narcosis, 
and decompression sickness. Aneroid sphygmoma- 
nometer and medications in glass containers in the 
emergency bag have withstood an addition of 5 at- 
mospheres without impairment. 

Gas-Poisoning Residuals. The effect of pressure 
will augment the toxicity of certain gases and cause 
concentrations of gases innocuous at surface pres- 
sures to become toxic. Should a compressor supply- 



U.S. NAVY MEDICAL NEWS LETTER 



ing a diver below or one being used to charge air 
tanks have its intake too near its exhaust or a 
source of carbon monoxide, carbon monoxide poison- 
ing could occur. 1 s The partial pressure of the carbon 
monoxide increases with depth and reaches toxic lev- 
els sooner. Similarly, any other noxious gases will 
have a greater tendency to cause headache and nau- 
sea under pressure, and these will simulate symp- 
toms of decompression sickness. 

Nitrogen narcosis or "rapture of the deep" begins 
to be noticeable at 150 feet and may have a serious 
intoxicating effect, particularly on a novice, at 200 
feet. Irresponsible, bizarre behavior will result, but 
the condition will be relieved by coming to shallower 
depths or the surface. 

Oxygen toxicity is dangerous because a grand-mal 
seizure may result without warning. Oxygenrich mix- 
tures or pure oxygen should not be used for under- 
water swimming. Nausea is another symptom of oxy- 
gen poisoning. A swimmer breathing pure oxygen 
at a depth of 30 feet for 15 minutes runs an ever-in- 
creasing risk of a grand-mal seizure with each sec- 
ond. This might explain -why a person would be 
brought to the surface unconscious and exhibiting 
signs of postconvulsive lethargy, if he was fortunate 
enough to have survived drowning. When using 
100% oxygen inhalation during treatment of de- 
compression sickness, one must watch closely for 
signs of oxygen poisoning. No one should use oxy- 
gen instead of air without being familiar with this 
possibility. The exact mechanism of oxygen toxicity 
is not known. 1G_1S Should oxygen poisoning occur, 
the high-pressure oxygen must be stopped 
immediately. 

Case 6. — A 23-year-old diver was working in 170 
feet of water for 30 minutes. He had to surface 
directly because of rough water and there was some 
delay in getting him into the decompression chamber 
on the surface. Decompression was accomplished on 
the appropriate schedule. About 90 minutes after 
decompression his arm began to hurt and kept him 
awake during the night. The next day a trial of de- 
compression in the water failed to relieve him. When 
seen at this hospital, his pain was not severe, but 
it was felt that he would be made more comfortable 
and complications might be forestalled by adequate 
treatment. An oxygen-equipped decompression 
treatment chamber was available and treatment was 
undertaken according to the Navy treatment tables 
for "pain only." The pain was not completely re- 
lieved even when he reached 100 feet. The pain 
in the elbow and knee disappeared at the 140-foot 
level. During the ascent on the treatment table he 



breathed 100% oxygen at 60 feet for 30 minutes 
and had no difficulty. He had been breathing oxygen 
for about ten minutes at the 50-foot level when he 
suddenly began to feel nauseated. The mask was 
immediately removed, but the nausea increased in- 
tensely for about another minute and then subsided 
just as rapidly as it had appeared. In five minutes 
he was able to resume the oxygen treatment schedule 
without difficulty. He had no symptoms on comple- 
tion of treatment and has had no residual effects. 

Reactions Not Due to Gas and Pressure Changes. 
Pain in the chest and joints, numbness, and other 
symptoms of decompression sickness may be simu- 
lated by emotional or organic medical problems, but 
with a number of confusing items in the history, 
it may be difficult to detect them. Someone swim- 
ming vigorously for a number of hours is certainly 
capable of having a myocardial infarction or other 
medical disaster. Exhaustion, fatigue, and other emo- 
tional reactions are common. 

Case 7. — A housewife who was taking scuba-div- 
ing lessons in a swimming pool was seen because 
of numbness of the lower half of the body. No im- 
pairment of muscular strength or reflexes was found 
on examination. Upon careful questioning it was 
learned that the patient agreed to take lessons only 
to please her husband and actually was extremely 
frightened by the whole procedure. Symptoms sub- 
sided rapidly on reassurance. 

Case 8. — A commercial diver complained of pain 
in the shoulder after repeated dives and hard work 
in depths which could have resulted in decompres- 
sion sickness. On physical examination the pain 
proved to be muscular, probably due to twisting of 
the shoulder. Relief was obtained after appropriate 
measures were instituted. 

Summary 

Five general types of underwater accidents due 
to gas and pressure exposure are discussed. Proper 
classification will lead to better treatment even 
though the physician himself is not familiar with 
skin diving. In an era when high-pressure (hyper- 
baric) environments are being discussed and used for 
research and treatment of various medical disorders, 
the casualties herein described, including ten men 
with permanent incapacitating injuries, serve as re- 
minders that high-pressure environments are dan- 
gerous, accidents will occur, and the physician must 
know what to do in an emergency. 

The US Navy Diving Manual is available from 



10 



U.S. NAVY MEDICAL NEWS LETTER 



the Superintendent of Documents, Government 
Printing Office, Washington, DC 20402, at $3.25. 

References 

1 Duffner, G.J.: Medical Problems Involved in Underwater Com- 
pression and Decompression, Ciba Sympos 10: 99-114 (July-Aug) 
1958. 

2. Skin and Scuba Diving Hazards and Medical Problems, Pfizer 
Spectrum 8; 156-165 (July) 1960. 

3 Vath, W.F, : Perilous Pleasures of Skin Diving, Today's Health, 
June 1963, pp. 14-19. 

4. Ford, K.L. : Medical Aspects of Skin and Scuba Diving, Texas 
J Med 58: 741-745 (Sept) 1962. 

5. Salzman, W.L.: Hazards of Scuba Diving, GP 26 <pt 2): 98- 
104 (Aug) 1962. 

6. Lanphier, E.H., and Gillen, H.W.: Management of Sports Div- 
ing Accidents, New York J Med 63: 667-671 (March 1) 1963. 

7. US Navy Diving Manual, Superintendent of Documents, Gov- 
ernment Printing Office, 1963. 

8 Butterfield, D.E., Mack, J.D., and Majno, Guido: Hazards to 
Health: Skin Diving, New Eng J Med 269: 147-149 (Aug 1) 1963. 

9. Taylor, G.D., Williams, E.H., and Chappell, G.L.: Skin and 
Scuba Diving Fatalities, J Florida Med Assoc 49: 808-810 (April) 
1963. 

10. Linaweaver, P. : Injuries to Chest Caused by Pressure Changes, 
Compression and Decompression, Amer J Surg 105: 514-521 (April) 
1963. 

11. Harvey, E.N.: Decompression Sickness and Bubble Formation 
in Blood and Tissues, Bull NY Acad Med 21: 505-536 (Oct) 1945. 

12. Mclver, R.G.: Medical Problems Encountered at High and 
Low Barometric Pressures, Illinois Med J 123: 611-618 (June) 1963. 

13. Coburn, K.R.: Decompression Sickness: Present Status, J Roy 
Nav Med Serv 48: 69-76, 1962. 

14. Rivera, J.C.: Decompression Sickness Among Divers, research 
report 1-63, US Navy Experimental Diving Unit, Feb 1, 1963. 

15. Meldrum, W.D., and Glass, W.I. : Carbon Monoxide Poisoning 
in Skin Divers, New Zeal Med J 62: 41-42 (Jan) 1963. 

16. Lambertsen, C.J., et al: Oxygen Toxicity, J Appl Physiol 8: 
255-263 (Nov) 1955. 

17 Slark, A.G.: Review of Medical and Physiological Problems of 
Working at High Pressure With Particular Reference to Diving, J 
Roy Inst Public Health 24: 269-274 (Nov) 1961. 

18. Gottlieb, S.F. and Jagodzinski, R.V.: Role of THAM in Pro- 
tecting Mice Against Convulsive Episodes Caused by Exposure to 
Oxygen Under High Pressure, Proc Soc Exp Biol Med 112: 427-430 
(Feb) 1963. 

THE U. S, NAVY'S SUBMARINE 
AND DIVING MEDICINE PROGRAM 

Training in the Navy's Diving Medicine Program 
is provided at the School of Submarine Medicine. 
This school convenes twice a year at the U. S, Naval 
Submarine Medical Center, Submarine Base, New 



London, Connecticut. Each class is approximately 
six months in duration. The curriculum includes: 
Basic Submarine Training, underwater physiology, 
hyperbaric physiology, psychiatry, dentistry, toxicol- 
ogy, environmental physiology and radiobiology. 
Successful completion of the course is creditable to- 
ward certification by the American Board of Internal 
Medicine and the American Board of Preventive 
Medicine. Upon completion of this course of instruc- 
tion, students are assigned to a tour of operational 
duty aboard a submarine or at a diving activity. 
During this tour, the student prepares a thesis and 
passes a comprehensive examination on submarine 
and diving medicine and is then designated a "Qual- 
ified Submarine Medical Officer." 

After completing a tour of duty with an operation- 
al unit, the medical officer may apply for post-grad- 
uate training in various fields. He may prepare for 
certification in preventive medicine and obtain a 
graduate degree by attending one of the Schools of 
Public Health or Industrial Medicine. He may 
prepare himself for a career in research and obtain 
a graduate degree in diving physiology or radiobiol- 
ogy by attending one of the appropriate civilian 
universities. 

Applications are accepted in the Bureau of Medi- 
cine and Surgery for the course which convenes in 
February and August of each year. 

Further information on Submarine and Diving 
Medicine may be obtained by writing to: Director, 
Submarine and Radiation Medicine Division, Bureau 
of Medicine and Surgery, Department of the Navy, 
Washington, D. C. 20390. 



FROM THE NOTE BOOK 



29TH ANNUAL EDUCATIONAL 
CONFERENCE 

The 29th Annual Educational Conference of the 
National Association of Sanitarians which will be 
held in Miami Beach, Florida June 20-24 is but 
a few months away. All of us should be thinking 
of these dates. 

The Florida Association of Sanitarians, the Host 
Association, is working diligently to make this con- 
ference one of the outstanding ones. General Chair- 



man, Charles Brettell, informs us that all committees 
are hard at work on the details at this early stage. 

The Deauville Hotel has been selected and ap- 
proved as convention headquarters. The Deauville is 
ideally located, (as it is situated on 65th to 67th 
streets and Collins avenue on the ocean, thus being 
in the exact heart of Miami Beach) and is but min- 
utes from any and all of the major attractions in 
the greater Miami area. 

The rates for this convention will be $12, 14, 



U.S. NAVY MEDICAL NEWS LETTER 



11 



and 16 for a double or twin bedroom, $10 for a 
single. A third person, child or adult will be $3. 
Those desiring the American Plan, which includes 
breakfast and complete seven course dinner nightly, 
will be available at $3 per person. 

Any and all members of the above convention 
wishing to arrive two days in advance or wishing 
to remain two days after the official convention has 
adjourned, can still enjoy the same convention rates 
if rooms are available. 

Other costs in which you may be interested are 
as follows: Annual Education Conference Registra- 
tion Fee will be $5.00. The Banquet with a night 
of entertainment will be in the area of $6.00 to 
$7.00. Also it is our hope to get a Vi price on 
children for the Banquet. 

Educational Program 

The theme of the 29th Annual Educational Con- 
ference of the National Association of Sanitarians 
is "Planning Together for Community Health." The 
topics that will be covered during the Educational 
Conference will be informative, interesting and chal- 
lenging to Environmental Health Personnel. The 
program will include talks and discussions on Air 
Hygiene, Radiological Health, Housing, Urban 
Renewal, food, milk, hospital, water pollution, small 
sewage treatment plants, pesticides, and administra- 
tive techniques. 

The keynote address at the opening general ses- 
sion will be Dr. Robert Anderson, Assistant Sur- 
geon General, United States Public Health. The title 
of his talk will be "Cooperative Planning for Meeting 
the Challenges of a New Society." Following Dr. 
Anderson's talk a reactor panel of top public health 
people from various parts of the United States will 
take place. 

In that a complete program will be printed in 
the March-April issue of this journal, we merely 
attempt to give you a few of the highlights of this 
program to date. 

In the Administrative Association, Professor Gil- 
bert Kelso now with the U.S.P.H.S. is in the 
process of arranging for a half day session on Ad- 
ministration techniques in Environmental Health. 
Briefly with an introduction into administration, fees 
for services, Advisory Committees and then a session 
on Performance Analysis — A discussion of the use 
of work load and cost studies in an Environmental 
Health program. There will be audience participa- 
tion in the preparation of a performance analysis 



study and its application to management decisions 
for a hypothetical program. 

At each conference industry plays a leading role 
in depicting products, services and equipment and 
their relation to public health, or to be more specific, 
their relation to getting the job done in public health. 
A panel discussion followed by audience participa- 
tion on the general topic of "Sanitarians Benefit 
from Close Working Relationship with Industry" is 
now in the making. 

Arthur F. Novah, Professor and Head Depart- 
ment of Food Science and Technology, Louisiana 
State University will present a lecture on Radiation 
Preservation of Food. 

Clarence Edwards of Quincy, Massachusetts will 
present a program on the "Use of Photography to 
Depict an Environmental Health Program." 

Orville Defrain of Lincoln, Nebraska will give a 
talk on "Professional Training for all Food Service 
Personnel." The program now in effect in Lincoln 
will eventually be used nation wide. 

In the area of Air Pollution, a staff of teaching 
personnel from the Robert A. Taft Sanitary Engi- 
neering Center in Cincinnati and headed by James 
Sheehy will cover such subject areas as: Air Pollu- 
tion and its effect on man, effects on property and 
vegetation, measurement of Air Pollutants and the 
control of Air Pollution. 

Leroy Houser of the P.H.S, Washington office 
will speak on the subject "Fifth National Shellfish 
Sanitation Workshop." 

A workshop on the Hospital Environment will 
be chaired by Erwin Krosnoff, University of Michi- 
gan Hospital. This should prove very enlightening 
in that it was at the 24th A.E.C. held in Miami 
that the N.A.S. held its first workshop on the Hos- 
pital Environment. 

The most urgent and all incompassing need 
throughout the country is to motivate and convince 
Hospital Staff and Personnel of the whys and hows 
of Environmental Health, beginning with hospital 
administration and working down. The key to this 
is to prove the positive relationship between Envi- 
ronmental Sanitation and infections. Many are work- 
ing on this all over the country, but the complexity 
of the problem is staggering. In any event, a better 
understanding of mutual goals and problems can re- 
sult from the session. 

Room does not permit us to continue, but please 
be assured that the 29th A.E.C. will be the best. 

More later! — Nicholas Pohlit, RS MPH, Execu- 
tive Secretary, National Association of Sanitarians. 



12 



U.S. NAVY MEDICAL NEWS LETTER 



SCIENTIFIC MEETING AND HISTORICAL 

EXHIBIT AT THE U.S. NAVAL HOSPITAL, 

ST. ALBANS, NEW YORK 

The United States Naval Hospital, St. Albans, 
N.Y., was host to the scientific sessions of the Asso- 
ciation of Clinical Scientists' Spring Meeting on 1 
May 1965. The Commanding Officer, CAPT John 
W. Albrittain, MC USN, welcomed Association 
members on board at 9:00 a.m. The Chairman of 
the Committee for all local arrangements was CDR 
Jeno E. Szakacs, MC USN, Chief of the Laboratory 
Service at St. Albans, assisted by the staff medical 
officers and residents of the laboratory service. 

The entire day was devoted to a "Symposium on 
Recent Advances in Clinical Science." Members and 
guest speakers were scheduled to deliver twenty-five 
papers in four sessions. The topic of the first session 
was centered on Laboratory and Clinical aspects of 
infection with Atypical Mycobacteria, (unusual 
forms of tuberculosis), supplemented by instructive 
exhibits on this important subject. These papers 
were presented by staff members of the Naval 
Hospital. 

The session after luncheon presented coagulation 
of blood in blood vessels and in the test tube. "Clot- 
ting of Fibrinogen" was discussed by Dr. K. Laki, 
of Bethesda, Maryland, "Disseminated Intravascular 
Coagulation in Diseases of Hypersensitivity," by Dr. 
Donald G. McKay of P. and S., Columbia Universi- 
ty, N.Y., Dr. Leon Sussman of New York presented 
data on "The Partial Thromboplastin Test." 

The two other sessions were devoted to a variety 
of subjects where progress in the last year was partic- 
ularly rapid; to name only a few papers, "Electron 
Microscopic Studies of Dedifferentiating Liver 
Cells," by Drs. Frederick F. Becker and Bernard 
Lane of New York University, Bellevue Hospital, 
"Human Chromosome Analysis," by LT Larry G. 
Dickson, MC USN, and "Gaschromatographic Anal- 
ysis of the Fatty Liver," by Irene Roeckel of the 
University of Kentucky, may be considered 
representative. 

Coincident with the meetings, the Historical Com- 
mittee of the Naval Hospital, headed by CAPT 
Arthur Errion, MC USN, arranged a unique Exhibit 
of Laboratory Instruments of the period 1700 to 
1900. Microscopes, hematology equipment, glass- 
ware from Louis Pasteur, and the armamentarium 
of the clinical chemist of the nineteenth century were 
well represented. Of special interest, particularly to 
New Yorkers, were the original Daguerreotype 



plates of Dr. J. W. Draper (1850) of the University 
of New York, representing the earliest form of pho- 
tography and an absolute first in photomicrography. 

The exhibit is open to the public from 8:00 a.m. 
to 5:00 p.m. daily through September. — Command- 
ing Officer, U. S. Naval Hospital, St. Albans, 
NY. 

IMPORTANT NEW APPOINTMENT 

George H. Reifenstein, MD, FACP has been ap- 
pointed to the newly established position, Technical 
Director of Clinical Research and Postgraduate Med- 
ical Education, in the Navy Medical Department. 
He will be responsible for evaluating the residency 
training program with a view to improvement of 
the teaching conducted in various specialties, and 
will also try to enhance the effectiveness of clinical 
research being carried on in the naval hospitals. Dr. 
Reifenstein brings to his high ranking assignment 
a rich background. He holds a Captain's commission 
in the Naval Reserve, of the Medical Corps and 
is President, Association of Hospital Directors of 
Medical Education. He is certified by the American 
Boards of Pathology and Internal Medicine, with 
the subspecialty-Cardio vascular Diseases. Over the 
years his experience has included clinical practice, 
teaching, research and laboratory work, and achieve- 
ments in anatomic pathology. He is also familiar 
with medicine in its Navy setting through tours of 
active duty and his background as Consultant at the 
U.S. Naval Hospital, Oakland, California. His pri- 
mary task to coordinate and strengthen the clinical 
research and training programs in naval hospitals 
is expected to yield important results. 

SECNAV— RETENTION POLICY BOARD 

I still consider the retention of high quality officers 
and enlisted men to be our number one personnel 
problem. The Secretary is completely mindful of this 
problem and is applying maximum effort towards 
its solution. He, as you know, has established a 
Retention Policy Board with himself as chairman 
supported by a Task Force headed by RADM John 
M. Afford to examine in depth the factors bearing 
on retention and to develop a plan for attacking 
these problems. SECNAV NOTICE 5420 of 29 Jan- 
uary announced the formulation of this effort and 
I wish all hands to know that it has my complete 
and enthusiastic support. This is an approach which 
can have far reaching beneficial effects on the Navy, 
and I will provide you with progress reports as they 
become available. 



U.S. NAVY MEDICAL NEWS LETTER 



13 



TENTH ANNIVERSARY OF THE 
INTRODUCTION OF THE POLIO VACCINE 

Dr. Luther L. Terry, Surgeon General of the Pub- 
lic Health Service, issued the following statement 
on the tenth anniversary of the licensing of the Salk 
vaccine April 12, 1955: 

"The tenth anniversary of the introduction of the 
polio vaccine by Dr. Jonas Salk finds us within vir- 
tual reach of a long-sought goal — the elimination 
of the disease in the United States. 

"Only ten years ago, there were over 28,000 cases 
of polio reported in the United States. In 1964 there 
was a total of 121. This represents an historic 
triumph of preventive medicine — unparalleled in 
history. 

"Dr. Salk's contribution, in terms of the reduction 
of human suffering, is immeasurable. On this tenth 
anniversary, I am happy to pay renewed tribute to 
his great achievement. 

"It is fitting that we also as a nation pay tribute 
to such pioneers as Dr. John Enders, who first devel- 
oped a way to grow the polio virus in quantity; 
Dr. Albert Sabin, who developed the oral vaccine, 
which has been widely used with fine results, and 
to the hundreds of organizations and thousands of 
individuals who have contributed their time and 
funds to a great cause. 

"It is also fitting to salute the tremendous contri- 
bution of the National Foundation and its President, 
Mr. Basil O'Connor. The Foundation not only fi- 
nanced the work of both Dr. Salk and Dr. Sabin 
but has worked with patience, ingenuity, and great 
effectiveness over the long years toward the conquest 
of polio."— USDHEW, Public Health Service. 

ACKNOWLEDGMENT 

CAPT John H. Cheffey MC USN desires that 
LCDR Guy Townsend MC USN also be included 
and credited for his splendid contribution to the ar- 
ticle "Humeral Torsion" Vol. 45, No. 6. Dr. Town- 
send is presently on duty at the U. S. Naval Hospital, 
Camp Pendleton California. 

ANNUAL MEETINGS 

The American Heart Association's 38th Scientific 
Sessions will meet October 15-17, 1965 and the An- 
nual Meeting will convene October 17-19, 1965 at 
the Americana Hotel, Bal Harbour, Miami Beach, 
Florida. 



The Council on Arteriosclerosis American Society 
for the Study of Arteriosclerosis 1 9th Annual Meet- 
ing will convene October 13-14, 1965 at the Deau- 
ville Hotel, Miami Beach, Florida. 

ARMED FORCES DAY 

On this Armed Forces Day, 15 May 1965, we 
of the United States Navy are proud of our continu- 
ing service to our country. We pledge ourselves anew 
to value the best of what is old, find the best of 
what is new, and meet with determination all chal- 
lenges which our part in the protection of our nation 
and of the American people bring to us. — ADM 
David L. McDonald, Chief of Naval Operations. 

CLINICAL RECORD, 
OPHTHALMOLOGIC CONSULTATION 

"DD Form 741 ( 10 63; Clinical Record, Ophthal- 
mologic Consultation, has never been adopted for 
general Navy use. This form does not appear in 
the Manual of the Medical Department nor is it 
available for issue thru the Forms and Publications 
Segment of the Navy Supply System. Clinical Rec- 
ord, Consultation Sheet (SF 513) is used for all 
consultations including Ophthalmological. Since this 
too is a clinical form, results are transcribed on 
Chronological Record of Medical Care (SF 600) 
in the individual's Health Record. Accordingly, the 
use of DD Form 741 should be discontinued and 
local stock destroyed and the above mentioned 
Standard Forms should be used in lieu of the DD 
Form 741." 

— Professional Div., BUMED 

NAVAL AVIATION MEDICINE'S STAINED 
GLASS WINDOW DEDICATED 

On Sunday, 14 March 1965, a Dedication Service 
was held at the Naval Aviation Memorial Chapel, 
Naval Air Station, Pensacola, Florida, commemorat- 
ing the installation of the Chapel's first stained glass 
window, Naval Aviation Medicine's "Christ, The 
Healer." Contributions in the amount of $3,500 
were received from active and retired medical 
department personnel from all over the Navy, the 
majority of which were connected with aviation 
medicine. 

The theme of healing is centrally portrayed in 
the window by the miracle at the pool of Bethesda 
when Jesus by His Divine power and simply speak- 
ing the words, "Take up thy pallet and walk," cured 
the man of his long infirmity. Standing in the back- 
ground is the scribe who sought to persecute Jesus 
for performing the healing on the Sabbath. 



14 



U.S. NAVY MEDICAL NEWS LETTER 



In the lower left Jesus is shown with the blind 
man whom He healed with the touch of His hand 
and dismissed with the words, "Thy faith hath made 
thee whole." 

At the lower right is depicted the dramatic story 
of the man with palsy, whose four friends, unable 
to reach Jesus because of the crowd, climbed to 
the housetop, removed some tile, and lowered their 
friend through the opening, bed and all, to the feet 
of Jesus. When Jesus saw their faith, He said to 
the sick man, "Thy sins are forgiven thee." 



RADM J. Floyd Dreith, CHC USN, Chief of 
Chaplains, was the guest speaker at the 0930 Cere- 
mony. Adding to the beauty of the occasion was 
the Naval Air Training Command Choir, who led 
the large group in singing hymns, concluding with 
their famous "Almighty Father." 

"Christ, The Healer," is a beautiful window, and 
a fitting tribute to our medical people. — Command- 
ing Officer, U. S. Naval Aviation Medical Center, 
Pensacola, Florida. 



DENTAL SECTION 



EFFECT OF PARTIAL DEFLUORIDATION 

OF A WATER SUPPLY ON 

DENTAL FLUOROSIS 

—RESULTS AFTER 1 1 YEARS 

H. S. Horowitz, F. J. Maier, and M. B. Thompson, 
Jour Pub Elth 54 (11): 1895-1903, 1964. 

For the past 1 1 years, excessive fluorides in the 
community water in Bartlett, Texas, have been chem- 
ically removed using activated alumina as the me- 
dium. During this period, the average level of 
fluoride delivered to water consumers has been 1.17 
parts per million. 

A base-line survey was conducted in 1954 using 
Dean's Classification to determine the extent of den- 
tal fluorosis among the continuous resident children. 
A follow-up examination was made in the fall of 
1963 after \\ l /i years of partial defluoridation of 
the water supply. 

Children ten years of age or younger in 1963 
had a mean fluorosis score of 0.43, compared to 
the base-line figure of 2.36 for this age group. Chil- 
dren 1 1 years old and over, whose period of tooth 
calcification overlapped the change in fluoride con- 
tent of the water supply, had a smaller reduction 
in average scores, which were 2.71 and 2.20 in 1954 
and 1963, respectively. 

While 94 percent of children aged ten or under 
examined in 1954 had positive signs of fluorosis, 
by 1963 only 21 percent exhibited mottling, and 
nearly all of these were the milder categories. No 
child ten or under was seen in 1963 with severely 



mottled teeth and only two exhibited moderate fluo- 
rosis. Dental fluorosis is still a serious public health 
problem in many areas of the United States. Persons 
living in nearly 400 communities consume water 
from public supplies containing more than twice the 
fluoride level considered as optimal. These commu- 
nities, therefore, fail to meet the minimum require- 
ments for public water supplies as established by 
the U. S. Public Health Service. Leaders in these 
cities and towns should take steps to adopt partial 
defluoridation in order to meet these standards and 
thus promote the well-being of their future 
populations. 

FACIAL PAIN 

A. P. Friedman, Oral Surg, Oral Med, 
and Oral Path 18(6) : 730-736, 1964. 

The underlying disorder causing facial pain may 
be anatomic, physiologic or psychologic. Three main 
categories may be used to classify the pain: (1) 
typical neuralgias, primarily neurogenic, (2) atypi- 
cal neuralgias, primarily vascular and psychogenic, 
and (3) facial pain secondary to other extracranial 
and intracranial causes. This discussion mainly cov- 
ers atypical neuralgias and their subdivisions. 

Atypical Neuralgias — Symptoms. The pain may 
be paroxysmal, of several hours duration, or con- 
stant; it does not follow the anatomic course of the 
cranial nerves; it is not precipitated by stimulation 
of a trigger area; it is usually described as a pressure 
or as a pulling, stabbing or drawing sensation. It 
is associated with autonomic nervous system signs, 



U.S. NAVY MEDICAL NEWS LETTER 



15 



such as lacrimation, nasal congestion, or increased 
skin temperature. The pain is not relieved by surgi- 
cal section of sensory nerve fibers, but is frequently 
relieved by vasoconstrictors. Commonly the condi- 
tion is associated with a personality problem. 

The pathogenesis of these neuralgias is still uncer- 
tain. However, there is fairly wide agreement that 
in some cases periodic attacks of local dilatation 
of extracranial vessels occur in areas mainly supplied 
by the branches of the external carotid arteries. This 
hypothesis seems to be supported, in some cases, 
by the presence of a distended temporal artery, in- 
jection of the eye, congestion of the nose, local in- 
crease in skin temperature, occasional relief upon 
compression of the temporal or carotid artery, and 
the usual good response to vasoconstrictive agents. 

Psychological aspects can play an important part 
in the various types of facial pain. Each individual 
will vary in his reaction to pain and a person's reac- 
tion to pain may be distinct from the sensation he 
is experiencing. Many of the patients do not recog- 
nize that they were under greater stress, or were 
emotionally upset or fatigued prior to an attack. The 
personality pattern most commonly observed was an 
adult who was ambitious, perfectionistic, over-con- 
scientious and efficient. However, facial pain may be 
a symptom of an anxiety state or depression. 

Facial Pain Secondary to Other Extracranial and 
Intracranial Causes. Some of these causes may in- 
clude pain of dental origin, tumors of the mandible 
and disorders of the temporomandibular joint, dis- 
orders of the nasal and paranasal structures (sinusi- 
tis), tumors of the nasopharynx, temporal arteritis, 
postherpetic neuralgia, referred pain from cervical 
disc and coronary thrombosis, tumors of the cranial 
nerves (mainly five and eight), intracranial tumors 
with secondary nerve compression, aneurysms and 
anomalies of blood vessels. 

The author has three tables included in his article 
which give some good comparisons or criteria in 
the various types of pain. 

(Submitted by: CAPT C. R. Parks DC USN, 
U.S. Naval Dental School, NNMC, Bethesda, Md.) 

SIMPLIFIED ENDODONTIC FILE AND 
REAMER CLEANING 

H. G. Greene, J ADA 70(1): 79-82, 1965. 

In this report an endodontist has devised a new 
method of cleaning endodontia files and reamers. 
With his technic, the operator is able to clean files 
and reamers and keep them free of dentinal debris, 



using only one hand and shortening his work time. 
The importance of not allowing a debris laden in- 
strument to enter the canal during the bioebemome- 
chanical phase of endodontic therapy is highly em- 
phasized and reasons for same are given. It is noted 
that other methods of instrument cleaning, i. e. wip- 
ing with cotton roll, sterile towel, gauze or rubber 
dam, requires both of the operator's hands. 

The technic suggested consists of snapping off 
heavy walled culture tubes the length of a $-7. cotton 
roll (1.5" or 37 mm) and inserting cotton roll into 
same. An inlay ring or the like is filled with stone 
or plaster, into which a lubricated culture tube is 
inserted. Just before the stone or plaster begins to 
set the tube is withdrawn. This provides a base hold- 
er for several of the sterilized cut culture tubes and 
inserted cotton rolls. A file or reamer can then be 
inserted into the canal, turned 14 or V2 turn, re- 
moved and inserted into cotton role and given a 
slight counterclockwise twist. This removes debris 
from between the flutes. The instrument is then steri- 
lized, reinserted into the canal and the cycle is re- 
peat. If at any time a new cleaner is desired, the 
old one can be instantly discarded and a new one 
is available. 

(Submitted by: LCDR Homer Clarke DC USN, 
NAS Norfolk, Va.) 

SNUFF DIPPERS' INTRAORAL CANCER: 

CLINICAL CHARACTERISTICS AND 

RESPONSE TO THERAPY 

R. L. Brown, J. M. Suh, J. E. Scarborough, 

S. A. Wilkins, and R. R. Smith, 

Cancer 18(1): 2-13, 1965. 

The incidence of cancer of specific organ sites 
varies strikingly in different geographic regions of 
the world and even in specific areas of a country. 
Oral and pharyngeal cancer is by far the most com- 
mon neoplasm in India and the Philippine Islands. 
The cancer institute of Madras reported 48% of 
all neoplasms were oral or pharyngeal in origin. 
More specifically 71% of oral cancers and 26% 
of all malignant tumors arose from the buccal muco- 
sa. By contrast, in the United States buccal cavity 
cancers accounted for only 4.6% of all newly diag- 
nosed cancers in males and 1.7% in female patients. 

Cancer morbidity studies suggest that oral cancers 
occur more frequently in low income than in high 
income groups. In India and the Philippines where 
the incidence of intraoral cancer is high and the 
economic status low, the use of tobacco with slaked 
lime and betel nut is associated with these cancers. 



16 



U.S. NAVY MEDICAL NEWS LETTER 



In the southeastern United States dipping snuff is 
a fairly common habit, especially among women of 
low income groups. It is suspected that this habit 
is associated with an increased incidence of intraoral 
cancer. 

This study was undertaken to: 1. Determine the 
assocation between the use of snuff and intraoral 
cancer. 2. To compare the biologic behavior and 
response to therapy of these cancers, to those seen 
in non-snuff users. 

A group of 394 intraoral cancer patients were 
studied with regard to exposure to snuff, tumor char- 
acteristics, type of therapy and survival. 

Results. In this study, patients with oral cancer 
were found to use snuff frequently, especially those 
with malignant lesions in the gingivo-buccal areas. 
The snuff dippers' cancer had the following charac- 
teristics: it occurred predominantly in women; it was 
associated more frequently with histologically low- 



grade tumors; it was also associated with an in- 
creased incidence of leukoplakia, new primary in- 
traoral cancers, increased regional metastases and 
increased 5 year survival rates. 

Those patients treated by surgery appeared to 
have a higher survival rate than did those treated 
by radiation. 

The 5 year survival rate for all intraoral cancer 
patients increased from 44% for the earlier portion 
of the study to 54% for those in the last part of 
the study. The 10 year survival rate was 27.5%. 

In the group of patients followed for 10 years 
most of the deaths during the last half of this period 
were due to disease other than the cancer respon- 
sible for the patient's first admission. 

(Submitted by: CAPT Seymour Hoffman DC 
USN, U. S. Naval Training Center, Great Lakes, 
Illinois.) 



PERSONNEL AND PROFESSIONAL NOTES 



Dietary Fluoride Supplements. Relative to BUME- 
DINST 11 330.1 A, stations of the Navy and Marine 
Corps, where children aged 16 years or less regularly 
receive the major portion of their potable water re- 
quirements from the station's water supply system, 
should take action toward fluoridating the station 
water. The cognizant dental officer shares responsibil- 
ity for support of this program (U. S. Navy Medical 
News Letter 43(10): 24, 1964). At some naval 
activities, unique situations have led to the question 
of whether dietary fluoride supplements (fluoride 
tablets, etc.) might not logically be substituted for 
base water fluoridation. A report on this subject, 
including a thorough literature search by CDR R. 
E. Austin DC USN, Consultant for Preventive Den- 
tistry to CINCLANTFLT Dental Officer, shows that 
dietary fluoride supplements have shortcomings as 
a substitute for water fluoridation. Two principal 
facts justify this position. First, a daily dose will 
cause a peak in the blood fluoride level followed 
by rapid elimination; and the amount of fluoride 
in the blood stream during most of the 24-hour day 
will be insufficient to cause an optimum deposition 
of fluoride in the enamel of developing teeth. Sec- 
ond, clinical tests have shown that average parents, 
after a short period of enthusiasm, will forget or 
neglect to ensure each child's daily taking of fluoride 
supplement. For these reasons, the cognizant dental 
officer should take the position that substitution of 



dietary fluoride supplements for fluoridation of base 
water is justified only when some engineering feature 
precludes fluoridation of the base water supply. 

Commendation for Service to the Fleet. In a letter 
dated 8 January 1965, the Commanding Officer, 
USS AMERICA (CVA-66) expressed his apprecia- 
tion to the Commanding Officer, U. S. Naval Dental 
Clinic, Norfolk, Virginia, for the very great service 
rendered to the pre-commissioning detail of AMER- 
ICA (CVA-66). The magnitude of this service was 
demonstrated by the fact that the Naval Dental Clin- 
ic, Norfolk, devoted over 12,000 appointments for 
dental treatment of all types to the crew during No- 
vember and December 1964, The Commanding 
Officer appreciated receipt of this treatment prior 
to the period of great need for shipboard training. 
He also stated that Naval Dental Clinic Norfolk's 
outstanding treatment had made a considerable con- 
tribution to the morale of his crew. To the commen- 
datory forwarding endorsements by Commander in 
Chief, U. S. Atlantic Fleet, Commander Naval Air, 
U. S. Atlantic Fleet and Commandant, FIFTH Na- 
val District, the Surgeon General was pleased to add 
his "well done." 

Sixteenth National Children's Dental Health Week 
February 2-8 1965. Typical of the Navy Dental 
Corps participation in the annual National Children's 
Dental Health Week, the following staff and student 



U.S. NAVY MEDICAL NEWS LETTER 



17 



dental officers of the U.S. Naval Dental School, Na- 
tional Naval Medical Center, Bethesda, Maryland 
presented lectures to nearly 2,000 students of eight 
area schools: 

CAPT G. H. Rovelstad DC USN 
CDR C. J. Swanson DC USN 
LCDR M. S. Davis DC USN 
LCDR C. J. McLeod DC USN 
LCDR H. O. Scharpf DC USN 
LCDR A. G. landoloDC USN 
LCDR B. E. Pines DC USN 
LCDR H. S. Tugwell DC USN 

Dental Officer Presentations. The Veterans Adminis- 
tration Hospital, Brockton, Massachusetts, with the 
joint sponsorship of the South Shore Dental Society 
held its 10th annual Dental Day, 17 February 1965. 
The program included a panel, "Meet the Deans", 
featuring RADM Clemens V. Rault DC USN 
(Ret.), former Chief of the Dental Division, and 
presently Dean, Georgetown University School of 
Dentistry. 

Also appearing on the program, CAPT Julian R. 
Con ant DC USN, US Naval Station, Newport, 
Rhode Island, presented a lecture entitled, "Local 
Environment Factors in the Etiology of Periodontal 
Disease-The Effect and Methods for Their Correc- 
tion." CAPT Conant is a Diplomate of the American 
Board of Periodontology. 

CAPT William R. Stanmeyer DC USN, Dental 
Officer, U. S. Naval Academy, Annapolis, Maryland, 
hosted a meeting of the Western Shore Dental So- 
ciety on 25 February 1965. In addition to those 
table clinics presented by the civilian members of 
the Society, the following table clinics were present- 
ed by dental officers of the Naval Academy: CDR 
"B" Frank Taylor DC USN, "Use of the Panorex 
in Diagnosis," LCDR Joseph A. Bodner DC USN, 
"Parallel Pins in Crown and Bridge," LCDR Wil- 
liam J. Watson DC USN, "Establishing the Bite in 
Crown and Bridge," and LT Thomas J, Cronin DC 
USNR, "Orthodontics in Preventive Periodontics." 

LT Joseph W. Lenihan DC USNR, Third Dental 
Company, Third Marine Division, presented a lec- 
ture entitled, "Emergency Care for the General 
Practitioner," in the Dental Office before the Oki- 
nawa Armed Forces Dental Society on 25 February 
1 965 at Fort Buckner, Okinawa. 

CDR Albert R. Smith DC USN, 4th Dental Com- 
pany Force Troops FMFLANT, presented a lecture 
entitled, "Preventive Periodontia," before the Feb- 
ruary meeting of the Camp Lejeune Dental Society. 

The Great Lakes Gold Foil Seminar was recently 



reorganized under the direction of CAPT Myron G. 
Turner DC USN, Dental Officer, U. S. Naval Train- 
ing Center, Great Lakes, Illinois. Officers of the 
study group are: LT G. T. Ballard DC USN, Presi- 
dent; LT R. G. Schonbrun DC USNR, Vice Presi- 
dent; LCDR T. J. Lommel DC USN, Secretary- 
Treasurer. Dr. Clifford Miller, Associate Professor 
of Operative Dentistry, Northwestern University, is 
the Seminar Director. 

The group recently featured a lecture and clinical 
demonstration by Dr. H. William Gilmore, Associate 
Professor and Chairman, Department of Operative 
Dentistry, Indiana University. 

CDR A. D. Echols DC USN, U. S. Naval Dental 
Clinic, Norfolk, Virginia, presented a lecture and 
conducted a discussion about "Removable Partial 
Dentures-Survey and Design," before the Delta 
Sigma Delta Study Club on 16 March 1965 in Nor- 
folk, Virginia. 

4th DENTAL COMPANY FORCE TROOPS 
FETED ON 1 4th ANNIVERSARY 

The following article appeared in a special supple- 
ment to the station newspaper, Camp Lejeune 
Globe, 1 April 1965: 

The only all-Navy command within Force Troops, 
the 4th Dental Company, is composed entirely of 
dental officers and technicians in sufficient strength 
to support a Marine Division, Marine Aircraft Wing 
or Force Troops. 

It is not intended that the company participate 
in the early phases of combat operation, but, upon 
establishment of a stabilized area, dental services 
will be concentrated where most effective. 

The 4th Dental Company, commanded by CAPT 
C. G. Veno DC USN, may mount out as a whole 
or it may be subdivided to support smaller units. 
It has the equipment to set up a clinic for one dental 
officer or as many as 25 dental officers. 

For a small unit in need of dental care, one dental 
officer and technician can be deployed with a trailer 
equipped with the necessities for a complete dental 
set-up. 

For larger operations CP and GP tents can be 
utilized to provide the space needed for all phases 
of dental care. In this way the company can take 
dental treatment to the unit rather than having its 
personnel travel to a central clinic. 

Dental personnel from the company participated 
in Operation "Steel Pike I" in October and Novem- 
ber of last year. Detachments of dental officers and 
technicians were dispatched to render underway 



18 



U.S. NAVY MEDICAL NEWS LETTER 



treatment to personnel aboard several ships of the 
Task Force, while the main body of the company 
embarked for passage to Spain. 

As the war games progressed, the 4th Dental 
Company joined the assault forces on the beaches 



of Spain and immediately became operative for den- 
tal emergency treatment. Within a matter of hours 
the company had reached its assigned campsite, 
erected dental clinic facilities, and was rendering 
routine dental treatment. 



OCCUPATIONAL MEDICINE 

ORTHOPEDIC EVALUATION OF EMPLOYEE FOR CONSIDERATION OF 
EMPLOYMENT IN HEAVY INDUSTRY 

John E. Burch, M.D., Miami, Fla., Industrial Medicine and Surgery 
34(2): 127-129, February 1965 



This paper represents the experience of the past 
seven years in formulating orthopedic examinations 
of prospective employees in heavy labor. While pri- 
marily our attention is devoted to disorders of the 
spine, we take into consideration the weight-bearing 
joints of the lower extremity, the hip, knee and 
ankle and also the important levers of the upper 
extremity representing the shoulder, elbow and the 
hand. 

I dislike the term Manual Labor, since all workers 
use their hands, but it is the association of the sec- 
ondary levers of the shoulders, spine and hips that 
makes a worker useful. The prospective employee 
is usually an adult male between eighteen and forty 
years of age, and presumably in good health and 
physical condition; but he may fool you. 

So you must be on your guard and look for hidden 
disabilities that might render the candidate a liability 
rather than an asset. A careful evaluation is made 
of function and range of motion of the spine and 
extremities on a fair objective basis associated with 
good technical x-rays of the lumbar or dorsal spine. 

Those candidates who have potential disabilities 
or deformities are rejected. The question of a fair 
risk for work is considered, but most recently all 
employers usually want applicants passed or not 
passed, no inbetween. However, it is sometimes 
desirable and necessary to accept for employment 
certain individuals who because of seniority have 
established themselves by prior employment in the 
plant or factory. As time goes on, however, it is the 
policy of management to adopt more rigid standards 
for employment. 



While this method of examination will not elimi- 
nate back injuries, it will tend to eliminate compen- 
sation claims that are based on congenital and 
structural defects of the spine that pre-existed. In 
addition, there will be a permanent record for man- 
agement which will show a pre-existing defect and 
will be useful when, in future injuries, it is alleged 
that the defects were caused by the said injury. 

It must be realized that the employer is legally 
permitted to protect himself from liability due to 
a pre-existing spinal weakness or deformity in a pros- 
pective employee by requiring a pre-employment 
physical examination. 

The employer should also realize that the medical 
examiner, with his most modern diagnostic equip- 
ment, cannot foresee the future, the accident rate 
in any worker, or the onset of a pathological disease 
process. 

I use the following criteria : 

1 . A Good Risk. Having no major defect of the 

spine or extremities, can be employed at any job 
requiring repeated strain or effort. 

2. A Fair Risk. Is sometimes not acceptable by 
certain areas of management. However, if this work- 
er by reason of previous employment desires promo- 
tion, and these defects are found which represent 
a fair risk, it is usually a process of bargaining be- 
tween labor and management to accept this employee 
for advancement. In this category, there are certain 
defects of the spine and extremities present but are 
of such a nature as to permit employment, but not 
continued back labor. 



U.S. NAVY MEDICAL NEWS LETTER 



19 



3. A Poor Risk. Is a rejectable applicant. This 
man has defects present of such a degree as to dis- 
qualify him for heavy lifting or other forms of heavy 
labor. It goes without saying that the examiner must 
be completely aware and have intimate knowledge 
of the requirements of the job for which the candi- 
date is applying. These categories in the electrical 
industry are usually spelled out in writing for the 
examiner so that he may decide whether this appli- 
cant could fit the type of job capacity. 

Three parts of the examination of the candidate: 

1. A medical history inquiring into previous dis- 
abilities of the spine and extremities, especially im- 
portant where there is a history of sport injuries in 
high school or college and in which no medical 
records are available. 

2. An adequate orthopedic examination of the 
spine and extremities. 

3. Careful exacting diagnostic x-rays are made. 
We make anterior, posterior, and lateral x-rays of 
the lumbar spine, and a spot lateral of the lumbo- 
sacral joint, right and left thirty- to forty- degree 
obliques of the lumbar spine to show the facettes and 
pars interarticularis portions of the spine. The 
oblique views are absolutely essential to rule out one 
of the most frequent congenital anomalies, bi-lateral 
or unilateral spondylolysis, which occurs at L-5, and 
sometimes L-4. Where there is previous history of 
fracture or dislocation of the upper or lower extremi- 
ty, an x-ray is also made of this area, if in the 
opinion of the examiner it is needed. 

Orthopedic Examination 

All examinations are conducted without clothes, 
shoes or socks, so that the spine may be examined 
and inspected from the base of the neck to the tip 
of the coccyx. It is very important to have back 
lighting, so that there are no shadows projected by 
the spine or extremities. 

Position I: Candidate stands barefoot, spine fac- 
ing you, heels and knees together, knees extended, 
hands at his side. It is most important to use your 
eyes for inspection and observation. Look for pelvic 
obliquity, lumbar lists, right or left scoliosis, fixed 
or mobile, flatness of the lumbar spine with loss 
of the lumbar lordosis, excessive lumbar lordosis 
with increased lumbosacral angle. Very often a drop- 
off at L-5 spinous process will indicate a spondylo- 
listhesis. The dynamics of the spine are then exam- 
ined by means of active flexion, extension, right 
and left bending, right and left rotation. During this 
examination, you must look for surgical scars such 
as a laminectomy, or areas that might have been 



fused, or other surgical procedures on the spine. 
Neck motion in flexion, extension, rotation and de- 
viation are also observed. You should also examine 
the candidate in this position: Arms abducted to 
determine the scapulo-humeral rhythm, and the pres- 
ence or absence of atrophy of the shoulder girdle 
muscles. 

Position II: With the patient facing you, examine 
the upper extremities, putting the candidate through 
the procedures of abduction, adduction, rotation and 
elevation of the shoulders, flexion, extension of the 
elbows, wrists, and fingers; careful inspection of the 
hands and fingers for opposition of the thumb to 
the opposing fingers, the presence of missing fingers, 
ankylosed joints, incomplete extension and residuals 
of peripheral nerve injuries. 

Position HI: With the patient prone on examining 
table, examine the spinal musculature with light 
pressure of fingers. If there is muscle spasm it will 
be felt as hardness of the muscle underneath the 
examiner's fingers and frequently associated with 
muscle tenderness. Ely's sign, flexion of the knee 
on the thigh, produces pain in lumbosacral disease 
and also sacroiliac disease. This position also is 
adaptable for checking the Achilles reflex. 

Position IV: With the patient supine on examin- 
ing table, check for active and passive straight leg 
raising. Active straight leg raising in a young indi- 
vidual who is not obese is ninety degrees above hor- 
zontal, however, this will vary with physical habitus, 
Brittain sign, the so-called Soto Hall sign with the 
patient sitting at lumbar angle of ninety degrees with 
the knees fully extended and the hips flexed ninety 
degrees. In discogenic disease and chronic sprains 
of the lumbar spine, individuals cannot do this with- 
out some low back discomfort, noticeable to the 
examiner. The Patrick test is done for sacroiliac 
pathology, and also Gaenslen's sign, facette rotation 
test with arms folded, grasping the elbows, the pelvis 
is rotated to right and left. In a candidate who you 
suspect has pre-existing low back disorders, dynamic 
test of the back using head-to-knee test and the so- 
called Williams sit-up exercise. 

The knee joint is then examined separately. You 
look especially for evidence of internal derangement 
of the knee, relaxation or laxity of the cruciate or 
collateral ligaments, presence or absence of increase 
joint fluid, the presence or absence of atrophy of 
th quadricepts mechanism. The range of motion 
in flexion and extension is determined and compared 
with the opposite knee. The ankle joint is examined, 
carried through its normal ranges of motion. Widen- 
ing of the ankle mortise is noted. Valgus position 



20 



U.S. NAVY MEDICAL NEWS LETTER 



of the foot in standing might indicate an old rupture 
of the libio-fibular ligament or the presence of an 
old healed Pott's fracture. 

Patient is asked to do a deep keee squat to deter- 
mine the flexibility of the hips, knees and ankles, 
and also to do the duck or monkey walk, which 
also indicates his ability to walk forward and back- 
ward in this position, and indicates the state of bal- 
ance. Candidate is then asked to walk forward and 
backward on his toes, heels elevated and backward, 
and then forward and backward on his heels with 
toes elevated. This is a balance test and also a func- 
tional dynamic test of the strength and integrity of 
the arches and structures of the foot and ankle. After 
these maneuvers are performed, then it is time to 
look at the x-rays. 

Summary 

1 . A pre-employment examination of the prospec- 
tive employee in heavy industry requires a careful 
orthopedic examination, correlated with proper x-ray 
studies of the spine. 

2. In order to be fair and impartial, the examina- 
tion must be conducted on a strictly objective basis. 

3. All candidates who by x-ray examination show 
evidence of multiple congenital defects which are 
considered disqualifying, associated with careful 
orthopedic examination of the spine are disqualified 
for heavy labor. 

These categories for selection of heavy labor are 
divided into : 

A. Good Risk 

1 . Four or six lumbar vertebrae. 

2. Un-united epiphysis of pars articularis. 

3. Mild asymmetrical changes of the posterior 
apophyseal joints. 

4. Spina bifida occulta of one segment. 

5. Schmorl's nodes. 

6. Transitional lumbar vertebra with solid fu- 
sion of one or both transverse processes to 
the ala of the sacrum. 

7. Increased lumbar lordosis. 

8. Un-united epiphysis transverse process. 

9. Normal anatomy of the lumbar spine. 

B. Fair Risk 

1. Spina bifida occulta of more than one 
segment. 

2. Schmorl's nodes at L-4, L-5 segments. 

3. Degenerative arthritic changes in the upper 
lumbar spine. 

4. Marked asymmetry of the facettes of the 
lumbosacral articulation with sclerosis. 

C. Poor Risk 

1. Spondylolisthesis of any degree. 



2. Bilateral spondylolysis. 

3. Transitional lumbosacral vertebra, lumbar- 
ized first sacral with articulation with the 
ala of the sacrum and pseudarthrosis 
formation. 

4. Degenerative disk disease L-4, L-5, S-l. 

5. Wedged vertebrae, two or more, residuals 
of juvenile epiphysitis. 

6. Hemangioma or any other tumor of 
vertebra. 

7. Osteoarthritis of generalized type of any 
degree. 

8. Clasp-knife deformity. 

9. Previous lumbar disk surgery, Marie-Strum- 
pel arthritis, osteoporosis, hemivertebra. 

Conclusion 

Careful examination of the spine and extremities 
with x-ray correlation will tend to eliminate candi- 
dates with definite or potential disabilities of the 
spine and extremities. 

Our rejection rate is about 9.6% of the 
applicants. 

The recurrent low back sprain or strain is still 
our number one problem in industry, causing many 
lost hours of work. 

The two areas of the spine that are most affected 
in lifting strains are the lumbosacral joint and the 
dorso-lumbar segment of the spine. The sprain of 
the lumbo-sacral junction is usually a flexion lifting 
sprain, or a fall in a flexed position. The dorsolum- 
bar sprain is usually a rotary, twisting type of sprain. 

Injuries of the knee joint associated with internal 
derangement, damage to the meniscus, and associat- 
ed injuries of the cruciate and collateral ligaments 
are the next most frequent injuries in our experience. 

Two of the most troublesome problems that the 
medical examiner encounters is that of the aging 
worker who has repeated back strains and back inju- 
ries and other associated joint injuries, and the obese 
worker under forty who becomes more or less a 
hazard to other workers, especially if his work en- 
tails climbing of electrical poles and steel ladders, 
utilizing climbing hooks. I think the incidence of 
disk injury and disk degeneration in adult males 
seems to be increasing. 

I do not agree with the majority of authors that 
this is related to our evolutionary experience in 
changing from a quadruped type of gait to an ortho- 
grade posture. Rather I feel it is related to a soft 
way of life, too much food, not enough exercise, 
improper conditioning of back, leg and shoulder 
muscles, fat bellies and soft backs. 

The answer to this latter problem might be the 



U.S. NAVY MEDICAL NEWS LETTER 



21 



development of physical conditioning, exercises 
during coffee breaks, and other periods while at 
work, to encourage the worker to remain physically 



fit. Also, in association with this a safety school 
to teach the worker how to avoid stress injuries to 
the spine and extremities. 



A REPORT ON PROTECTION OF LONGSHOREMEN FROM CHEMICAL SPILLS 

Safety Standards 14(1), January-February 1965* 



What his nose knows about carbon monoxide 
doesn't help a longshoreman much. It's an odorless 
gas and can be lethal. But like the rest of us, he's 
likely to become wary in the presence of a strong, 
unfamiliar odor, and hesitant to slop around in a 
liquid which burns on contact. Also like all of us, 
he's apt to be guided by his senses — put up with 
an odor if it's not too unpleasant, wipe up something 
by hand if it doesn't hurt his skin immediately, and 
not worry too much about breathing and swallowing 
a little dust if it doesn't taste bad or choke him. 
Unfortunately, the longshoreman's senses do not 
give him timely warning of many chemicals. And if 
the bag or drum which contains the chemical being 
transported is ruptured, he can be in trouble before 
he finds out that the substance is harmful. 

Even though all chemical products manufactured 
and used in industry — many of them toxic, corrosive, 
or flammable — are transported by land, sea, and 
air, workers should encounter no chemical hazards. 
Normally longshoremen and other transportation 
workers are not exposed to these hazards because 
the chemicals are packaged to contain the product. 
These workers handle the sack, drum, box, or other 
package — not the product itself. Thus, exposure to 
chemicals in longshoring aboard ship, or in any oth- 
er form of transportation, is in itself an accident. 

Except for dusty cargoes in bulk or in loose mesh 
sacks, exposure usually occurs when the container 
leaks or is ruptured. Although accidents of this type 
are common, fortunately most exposures have been 
harmless or have had minor effects. Despite the large 
variety and tonnage of chemical products handled 
each year, the injury record is reasonably good. For 
example, last year, a total of 22,500 injuries were 
reported to the Bureau of Employees' Compensa- 
tion. Of these, 375, or 1.7 percent, involved expo- 
sure to fires and hazardous chemical cargoes. 



♦ Adopted from a paper presented by Ralph W. Netterstrom, Chief, 
Division of Maritime Safety, Bureau of Labor Standards. U.S. De- 
partment of Labor, before 52nd National Safety Congress, October 
3964. 



Accident Potential Always Present 

Nevertheless, if adequate safeguards are not taken, 
the potential for a serious accident is always pres- 
ent. In the past two decades there were several 
disastrous cargo fires in this country which took the 
lives of men aboard ship. In one case, two men 
were killed by carbon dioxide used as a refrigerant. 
In two cases, one on the ship and one on the dock, 
large chlorine cylinders developed massive leaks and 
many longshoremen suffered varying degrees of ex- 
posure. In several cases, men were exposed to fumi- 
gated grain or baled cargo which had not been prop- 
erly aerated before being loaded aboard the vessel. 
Among any group, a few are allergic to a specific 
product — castor beans, for example. Several years 
ago, there were cases where entire gangs developed 
allergic and toxic symptoms from a castor bean 
product. 

In 1958 the passage of Public Law 85-742 em- 
powered the Secretary of Labor to promulgate and 
enforce safety regulations and to promote safety in 
employment under the Longshoremen's and Harbor 
Workers' Compensation Act. Mainly the Depart- 
ment's concern involves longshoring and ship repair- 
ing aboard ships and in some cases shipbuilding and 
shipbreaking on vessels afloat. Other Federal agen- 
cies are also involved. The Coast Guard and the 
Interstate Commerce Commission, through their 
control of packaging and stowage, as well as the 
Department of Labor through its safety regulations 
are all working to reduce the hazards involved in 
transporting chemicals. 

The Coast Guard has placed stringent regulations 
on the handling of ammonium nitrate to prevent 
a repetition of the 1947 Texas City ship explosion 
that took 550 lives. The hazard of CO 2 from dry 
ice. has been eliminated by prohibiting its stowage 
below deck. The Department of Labor now requires 
the stevedore to make certain (rather than to assume) 
that fumigated cargo has been properly aerated. 
It has also joined forces with the Coast Guard, the 
International Longshoremen's Association, and im- 



22 



U.S. NAVY MEDICAL NEWS LETTER 



porters to ban shipment of untreated castor pomace 
and to improve packaging to further reduce the ex- 
posure to dust or castor beans. 

Handling Chlorine Leaks 

In the case of the chlorine leak aboard ship, 
Department experts found widespread ignorance of 
the necessary precautions to take when a leaking 
cylinder is discovered in the hold of a vessel. The 
problem was studied and in cooperation with the 
Chlorine Institute a pamphlet was prepared and dis- 
tributed to the industry. Application of the informa- 
tion can prevent a repetition of massive leaks and 
the consequent dangerous exposures of large num- 
bers of men. The pamphlet stresses the need for ex- 
treme care in handling cylinders to avoid fracturing 
them by dropping. 

Those who work in plants that use chlorine daily 
and who are familiar with its properties, hazards, 
and means of preventing leaks and protecting against 
exposures may raise the question: Why doesn't the 
stevedore know about it? There are two reasons: 
One is that he may never handle this product. The 
other, he may have handled cylinders from time to 
time and possibly never smelled the chlorine because 
the containers performed their function and allowed 
none to escape. Chlorine handling is typical of the 
situation many employers face in handling a wide 
variety of chemicals. A stevedore may never handle 
some of these; others he may handle in relatively 
small quantities in a given lot, and longshoremen 
rarely are exposed to the toxic products they work 
with. Nevertheless, accidental exposure is always 
possible and the question remains: What to do when 
the bag breaks? 

Practically, the solution lies in supplying necessary 
information and warnings before the emergency 
arises so that workers will not have to rely on their 
senses to avoid exposure. 

Uniform Labeling A ids Safety 

Labeling of packages is one solution. The Manu- 
facturing Chemists' Association has developed a set 
of recommended labels for use on many specific prod- 
ucts and a number of manufacturers use them. The 
familiar red, yellow, green, and white labels required 
by the Coast Guard and the ICC on many hazardous 
cargoes are of great value but they cover broad cate- 
gories of products and cannot give all of the infor- 
mation required. Language differences in interna- 
tional trade are a problem the International Labor 
Organization has been attempting to overcome 



through adoption of a uniform set of pictographs 
to indicate flammables, corrosives, toxics, etc. While 
valuable, they, too, are limited in the amount of 
information they can convey. 

It is not practical to require the stevedore to ob- 
tain information on his own because of the present 
difficulty of obtaining the necessary information in 
all cases. The Coast Guard regulations ("Explosive 
or Other Dangerous Articles and Substances and 
Combustible Liquids on Board Vessels") cover 
more than 1,800 specific items, and specity packag- 
ing and stowage requirements aboard various types 
of vessels. Some products must be on deck where 
they can be watched and, if necessary, washed over 
the side; others must be kept away from heat (as 
from boiler spaces); others cannot be stowed with 
products with which they would react if mixed. The 
regulations indicate which cargoes must be labeled. 

The Coast Guard's regulations also contain infor- 
mation on the hazardous properties of substances 
and general precautions to be taken. They do not 
necessarily require that the chemical name of all 
products be placed on the package but that it be 
listed on the manifest with identifying marks on the 
cargo so that the ship operator and stevedore will 
know what the product is. Manifest requirements 
apply to imports as well as to exports. 

The Department of Labor is now preparing a 
pamphlet which will indicate, for each of the com- 
modities listed, hazardous products and precautions, 
including emergency equipment, necessary for han- 
dling leaking or ruptured containers. This publica- 
tion will indicate those commodities which could de- 
velop flammable atmospheres and whether the gas 
or vapors would tend to diffuse through the open 
hatch or tend to accumulate in the bottom of the 
hold; which incipient fires can be extinguished by 
water and those that would spread with use of water; 
which commodities will do little harm in brief and 
infrequent skin contacts and those to be avoided 
entirely; which specific type of respiratory protective 
equipment should be worn as well as conditions un- 
der which it is unlikely to be needed. Information 
on symptoms of over-exposure and first-aid treat- 
ment, with particular reference to those cases which 
should receive medical attention, will also be in- 
cluded. 

Correct Identification Important 

By checking the dangerous cargo manifest for 
commodities he may have to handle and the marks 
on the cargo by which he can identify them, and 



U.S. NAVY MEDICAL NEWS LETTER 



23 



then by referring to the pamphlet, the employer will 
have the information he needs. He will then be able 
to pass on to supervisors and, when necessary, em- 
ployees information on what to do in any situation 
which may arise in terms of protective clothing, res- 
pirators, gas masks, or other respiratory protective 
equipment, and precautions to be taken in cleaning 
up and disposing of spilled material. 

Although it will take some time to complete this 
project, the Department expects that it will serve 
as an aid to employers in minimizing worker injuries 
from toxic and flammable cargoes. In addition to 
longshoring, the information will be useful in other 
forms of transportation as well. Manufacturers will 
be encouraged to make similar information available 
to their customers. 

Recent developments are encouraging. The 
Department observes that more and more stevedores 
and longshoremen are recognizing the potential haz- 
ards of spills. The workers tend to be more wary 
and stevedores are beginning to call in chemists to 
advise on the degree of hazards and means of over- 
coming it. 

The Coast Guard has recently contracted with the 
National Academy of Sciences for research assist- 
ance in dealing with hazardous cargoes, especially 
the increasing number of bulk shipments. Two Acad- 
emy committees — Hazardous Materials and the 
Advisory Center on Toxicology — are working on the 
project. The results will yield technical data needed 
by the Coast Guard to develop regulations to protect 
vessel operating personnel, men who handle loading 
and unloading, and the general public from exposure 
to chemical hazards. 

Thus, the regulatory agencies involved, as well 
as employers and unions, are continuing the search 
for information and methods to further safeguard 
workers and the public from hazards involved in 
transporting chemicals. The fact that products being 
shipped are increasing in variety and tonnage not 
only permits no letup, but calls for intensified safety 
effort. 

HAZARDS OF ALLOYS 

AND SEMIMETALLICS 

OF THE FERROALLOY INDUSTRY 

Industrial Hygiene New Report 8(2), February 
1965. 

In the ferroalloy industry, there is considerable 
production of nonferrous and special alloys and 
semi-metallics in which combustion and toxicity haz- 
ards of varying degrees are produced. A run-down 



of the actual and potential hazards of more than 
60 specific compounds is detailed in a report appear- 
ing in two parts in the January and February, 1965, 
issues of the Journal of Occupational Medicine. The 
report, by Warren C. Roberts, MD, Chief of Medical 
Services, Western Electric Company, Buffalo, N. 
Y., is based on the author's 15 years' experience, 
rather than on critical investigative work. Some of 
his information in summary is given here: 

Generally the lump-size alloys are harmless to the 
health and the chance of combustion of lump-size 
alloys is remote unless they are mixed with fumes 
or a gas-forming alloys is present. Most alloys will 
ignite if the particles are 200 mesh and down. Class 
2 (actively combustible) will ignite at 100 mesh 
and down. Class 1 (highly combustible) will ignite 
at 8 mesh and down. Titanium metal will ignite in 
the lump size under great shock and will resist all 
the usual methods of extinguishing the combustion. 

Certain alloys will yield combustible and toxic 
gases on exposure to a mist atmosphere at room 
temperature. Ferrosilicon and calcium-manganese-sil- 
icon will yield hydrogen and phosphine gas. Calcium 
silicon produces hydrogen, silane, and phosphine 
gases. Low-iron ferromanganese will spontaneously 
break down to manganese carbide, which will pro- 
duce acetylene gas. Aluminum carbide will produce 
methane gas. Magnesium-calcium-silicon produces 
hydrogen and silane gases on contact with acids. 
Barium silicon produces hydrogen and silane gases 
on contact with acids. Barium silicon produces silane 
and hydrogen gas on exposure to air, and occasion- 
ally acetylene gas. 

Nitride and boron alloys are generally inert and 
nontoxic, presenting no significant health hazard. 
Carbides of aluminum, boron, chromium, tantalum 
and titanium have not produced pulmonary damage 
or pneumoconiosis. Tungsten carbide is only a sus- 
pected agent in pulmonary irritation, but vanadium 
carbide is a definite (though mild) pulmonary irri- 
tant, and prolonged exposure could possibly produce 
permanent pulmonary damage. Chromium alloys are 
nontoxic and have not produced any skin reactions 
or pulmonary changes, nor have produced an in- 
creased incidence of pulmonary cancer. The crush- 
ing operations and production of manganese alloys 
have not produced any significant cases of central 
nervous system damage in the ferroalloy industry 
in the United States. Molybdenum, tungsten, titan- 
ium, and tantalum alloys are harmless. 

Alloys of silicon metal do not produce silicosis. 
The fumes, which are evolved in great quantity in 



24 



U.S. NAVY MEDICAL NEWS LETTER 



the furnace production of ferrosilicon, is a question- 
able cause of silicosis. Vanadium alloys will produce 
upper respiratory and bronchial irritation, and co- 
lumbium has a slight tendency in this direction. Al- 



lergic reaction of the skin and respiratory tract to 
most metals and alloys is uncommon. Cobalt and 
nickel occasionally may cause an allergic dermatitis 
or bronchial asthma. 



MISCELLANY 



JOINT MEETING BETWEEN 

BROOKLYN SURGICAL SOCIETY AND 

STAFF OF THE U. S. NAVAL HOSPITAL, 

ST. ALBANS, N. Y. 

The annual Spring scientific meeting between the 
Brooklyn Surgical Society and the staff of the U.S. 
Naval Hospital, St. Albans, New York, was held 
on Thursday, 1 April 1965, at State University of 
New York Downstate Medical Center. Papers were 
presented by members of the host society and dis- 
cussed by members of the staff of the U. S. Naval 
Hospital, St. Albans, N. Y. The program was as 
follows : 

"Experimental Transplantation 

of an Auxiliary Liver" — 

Marvin L. Gliedman, MD 

Associate Professor of Surgery 

Discussor: Charles B. Volcjak, LT MC USN— 

Surgical Service 

"Electrical Pacing of the Heart" — 

Karl E. Karlson, MD 

Professor of Surgery and Head of 

Thoracic Surgery 

Discussor: Homer S. Arnold, CDR MC USN 

Head of Thoracic Surgery 

"Fracture Healing In Experimental Diabetes" — 

Horace Herbsman, MD 

Instructor in Surgery 

Discussor: Charles H. Emich, LCDR MC USN 

Orthopedic Service 

"Basic Studies on 

Massive Gastroduodenal Hemorrhage" — 

Irving F. Enquist, MD 

Professor of Surgery 

Discussor: William R. Blakeley, LCDR MC 

USNR Surgical Service 

The professional program was followed by a so- 
cial hour and the Forty-First Annual Invitation 



Dinner in honor of the staff of the U. S. Naval 
Hospital, St. Albans, which was held at the Hotel 
Granada, in Brooklyn. 

Seated on the dais with Dr. Clarence Dennis, Pres- 
ident of the Brooklyn Surgical Society, were other 
officers of the host society, senior officers of the 
St. Albans Naval Hospital staff and presidents of 
the several surgical societies in the Brooklyn- 
Queens-Long Island area. The featured speaker at 
the dinner was Dr. David Dingman, currently a sur- 
gical resident at the University of Maryland. Dr. 
Dingman spoke on his experiences as a member of 
the successful United States assault on Mt. Everest 
in 1963. 

The close and friendly association with the Brook- 
lyn Surgical Society, which is one of the oldest surgi- 
cal societies in the Nation, dates back to 1 924 when 
the first meeting was held between this Society and 
the Staff of the U. S. Naval Hospital, Brooklyn, 
New York. Since that time, reciprocal meetings have 
been held each year except for an interruption 
during World War II. Each year, the Spring meeting 
is hosted by the Brooklyn Surgical Society and the 
winter meeting by the U. S. Naval Hospital staff. 
In recent years, the Naval Hospital at St. Albans 
replaced the Hospital at Brooklyn as the participant 
in these joint meetings. — Commanding Officer, U.S. 
Naval Hospital, St. Albans, New York. 

SAB, BOARD OF GOVERNORS 
MEET AT AFIP 

The Armed Forces Institute of Pathology Board 
of Governors and the Scientific Advisory Board both 
met at the Institute recently. 

RADM Robert B. Brown, MC USN, the new Sur- 
geon General of the Navy, attended his first meeting 
as a member of the Board of Governors. RADM 
Brown succeeded retired Surgeon General RADM 
E. C. Kenney on the Board. 



U.S. NAVY MEDICAL NEWS LETTER 



25 



A certificate of appreciation for RADM Kenney's 
outstanding support and loyalty to the AFIP while 
serving as a member of the Board of Governors 
was presented to the retiring Surgeon General 
by AFIP Director Brig Gen Joe M. Blumberg. The 
citation was presented in the Surgeon General's 
office in a special ceremony also attended by RADM 
Brown and AFIP Deputy Directors CAPT Bruce 
H. Smith, Jr., and LT COL David Auld, 

At the meeting of the Scientific Advisory Board 
of Consultants, Dr. Howard T. Karsner, a pioneer 
in pathology and longtime friend of the AFIP, was 
named an honorary lifetime member of the Board. 
A certificate to be presented to Dr, Karsner stated: 
"For a lifetime of loyal and dedicated service to 
the Armed Forces Institute of Pathology (Howard 
T. Karsner) is hereby named honorary life member 
of the Scientific Advisory Board." The citation will 
be presented to Dr. Karsner by The Director. — A- 
FIP Letter, Apr 1965. 

DIRECTORY OF 
POISON CONTROL CENTERS 

A newly revised directory of the 545 poison con- 
trol centers now operating in the United States and 
possessions was issued by the Public Health Service's 
Division of Accident Prevention, U. S. Department 
of Health, Education, and Welfare. The revised di- 
rectory, Public Health Service Publication No. 1278, 
replaces the directory published in August, 1962. 

The new "Directory of Poison Control Centers," 
compiled from information furnished to the National 
Clearinghouse for Poison Control Centers by State 
health departments, lists the address, telephone 
number and directing personnel of poison control 
centers functioning in 469 cities in 48 States, and 
in the Canal Zone, District of Columbia, Guam, Pu- 
erto Rico and the Virgin Islands. 

The centers listed in the directory function inde- 
pendently within State poison control programs. 
They are supported with information and technical 
data services by the National Clearinghouse for Poi- 
son Control Centers, operated by the Poison Control 
Branch of the Division of Accident Prevention. 

The new directory includes centers which provide 
round-the-clock information services for the medical 
profession concerning the prevention and treatment 
of accidents involving ingestion of poisonous and 
potentially poisonous substances. It is available for 
20 cents from the Superintendent of Documents, 



Government Printing Office, Washington, D. C. 
20402.— USDHEW, Public Health Service. 

CONSTRUCTION GRANTS AWARDED 

Three new medical schools are being awarded 
construction grants totaling $25,321,347, Secretary 
of Health, Education, and Welfare Anthony J. Cele- 
brezze announced. 

The grants are being made to the University of 
Texas for the South Texas Medical School and an 
affiliated teaching hospital, Bexar County Hospital, 
both to be located in San Antonio; to Rutgers Uni- 
versity for a School of Medicine, in New Brunswick, 
N. J.; and to the University of California for a 
School of Medicine, in San Diego. 

With the award of these grants, 33 projects have 
thus far been aided, in the amount of $77,188,797, 
under provisions of the Health Professions Educa- 
tional Assistance Act of 1963. The Public Health 
Service is responsible for administering the Act 
which provides grants to stimulate construction of 
additional educational facilities for those health pro- 
fessions which are experiencing serious manpower 
shortages. 

The awards related to the new South Texas Medi- 
cal School total $12,948,581, with $3,948,581 for 
the medical school and $9,000,000 for the 13-story 
teaching hospital which will have 476 beds. The 
medical school plans to provide spaces for an enter- 
ing class of 100 students. 

Rutgers University, which will receive $4,337,519, 
is planning to construct a two-year medical school 
which will accommodate 64 students in 1966 and 
80 in 1971. 

The new University of California School of Medi- 
cine, which is being aided in the amount of 
$8,035,247, will be a 5-story structure and will be 
one of 1 3 separate colleges to be located on the new 
San Diego campus. 

The grants were made on the recommendation of 
the National Advisory Council on Education for 
Health Professions. Council members represent the 
general public as well as each of the health profes- 
sions authorized to receive aid under the Act. 
—USDHEW, Public Health Service. 

1943 WAVE RECRUIT RECALLS 22 YEARS 
SERVICE WITH NAVY 

By Byron S. Whitehead, J02 

In the summer of 1943, shortly after the WAVES 
were organized, eighteen young women wearing 
Navy Blues arrived for duty at a San Francisco naval 



26 



U.S. NAVY MEDICAL NEWS LETTER 



communications station where the skipper refused 
to accept them because he had never heard of such 
a thing as "women in the Navy." 

A phone call to the Treasure Island Naval Base 
soon cleared the way for the girls' assignment, and 
eventually, 26 sailors were freed from shore duty 
tasks and transferred to sea. 

For one WAVE recruit this episode was the first 
of many during 22 years with the Navy. 

Today, that same girl, Katherinc Keating, is a 
commander in the Medical Service Corps, assigned 
as Chief of Pharmacy Service at the U. S. Naval 
Hospital, Yokosuka, Japan. 

Born in Pueblo, Colorado, she is the daughter 
of Mrs. Cecil Keating. Her first contact with the 
Navy began at the University of Colorado in Decem- 
ber, 1942, while she was a student. 

"I had read in the papers that a U. S. Navy re- 
cruiting van would pass near our university to enlist 
women. Patriotism was so high at this time that 
enlisting seemed like the only thing to do," said Miss 
Keating. 

Miss Keating received her recruit training at 
Hunter College, New York. 

"I was looking forward to better things in the 
Navy but found myself peeling potatoes eight hours 
a day for the first three weeks. Can you imagine 
how many potatoes it takes to feed 2,000 girls?" 
she asked. 

"Its funny," she said, "we didn't get our uniforms 
until three days before graduation, and on that day 
we paraded for the visiting Madame Chiang Kai- 
Shek." 

Upon graduation from recruit training she had 
her choice of four rates to enter. The four rates 
were yeoman, radioman, storekeeper, and aerog- 
rapher. 

"If you could tell the difference between a dot 
and a dash you were assigned to radio school," she 
noted. 

Of the first, 2,000 enlisted WAVES to enter the 
Navy, 400 were transferred to the Radio School at 
the University of Wisconsin, including seaman ap- 
prentice Keating. 

After 19 weeks of radio training, she was ad- 
vanced to third class radioman and received her first 
set of orders. 

With 17 other WAVES she headed for San Fran- 
cisco. It was here she met the skipper who didn't 
want women and sent them packing to Treasure 
Island. 



At Treasure Island no accommodations were 
available for women. 

"The commanding officer had the top deck of 
the Armed Guard Barracks cleared and bunks put 
in for us. A guard was posted at the foot of the 
steps leading up to our room. The big joke then 
was who was going to watch the guard," she said. 

One foggy night while assigned to the distress fre- 
quency radio control section on Treasure Island, she 
received an SOS from the liberty ship SS Henry 
Bergh. The Bergh, returning to the U. S. with WW 
II casualties, had run aground on rocks about 25 
miles out of San Francisco. Miss Keating immediate- 
ly informed search and rescue units, giving them 
the ship's position, thereby making it possible for 
them to rescue all patients and crew aboard the ship. 
For this action, the WAVES received special no- 
tice from other naval commands and suddenly 
WAVE radiomen were in great demand. 

After a year at Treasure Island she volunteered 
for duty in Hawaii. 

"I'll never forget it," she says, "I boarded a troop 
transport along with 200 other WAVES. The nine- 
day trip to Hawaii was a rough experience. I was 
the world's most seasick person. We were berthed 
in a compartment with bunks five high. I had the 
bottom bunk. When the girl in the fifth rack got 
sick, I got the worst of it." 

En route to Hawaii the WAVES stood watches in 
the radio control room. 

"The chief petty officer felt sorry for me and 
placed a bucket at my feet so I could work and 
get sick at the same time," she said. 

With the arrival of the WAVES in Hawaii, sailors 
at the Wahiawa Communications Station were able 
to go off port and starboard duty and onto three-sec- 
tion watches because of the WAVES assistance. 

At Wahiawa she was advanced to radioman first 
class. With the war in the Pacific over, she was 
discharged and reentered the University of Colorado 
where she attained a B. S. Degree in Pharmacy. 
At the same time she entered the Reserves. 

After graduation, she returned to active duty as 
an RM2. 

With her degree in pharmacy, RM2 Keating 
hoped to switch to the hospital corps rate but the 
Navy kept her in radio work. 

Her first assignment after re-enlisting was at Na- 
val Air Station, Seattle, Wash., where she was the 
only WAVE radioman in the Thirteenth Naval 
District. 



U.S. NAVY MEDICAL NEWS LETTER 



27 



Miss Keating's assignment to an all male crew 
presented a problem for the Communications Offi- 
cer. Since the latter was an aviator, he used her 
as his radioman on aircraft flights. 

From Seattle it was back to Treasure Island again 
where she worked on the staff of Commander, West- 
ern Sea Frontier. Here, she was again advanced 
to RM1. 

At this time a critical shortage in hospital corps- 
men arose and Miss Keating was authorized to 
change her rate to HM1. 

Two months later she was advanced to the rank 
of ensign. 

Although most new ensigns are trained at Officer 
Candidate School, Ensign Keating was ordered in- 
stead to the Naval Air Station, San Diego. 

"It was in San Diego that I got my baptism of 
fire as the original ensign with two left feet. There 
never had been a Pharmacy Officer there before, 
let alone a female," says Miss Keating. 

In December, 1953, Miss Keating reported 
aboard the U. S. Navy hospital ship Haven at Long 
Beach which promptly deployed to the Korean con- 
flict area. The Haven remained in Korean waters 
until completion of prisoner-of-war exchanges. 

From Korea, while still aboard the Haven, she 
went to Saigon to assist in evacuating French For- 
eign Legion survivors from Dhien Bien Phu. 

En route to Algeria the ship celebrated its equator 
crossing. 

In addition to the Golden Dragon, she holds 
Shellback and Magellan certificates. 

From 1955 to 1964, Miss Keating served in naval 
hospitals at Mare Island, Oakland, and Memphis. 

In January, 1964, she became officer-in-charge 
of the Pharmacy Technicians School at San Diego. 
Seven months later she accepted orders to the 
U.S. Naval Hospital, Yokosuka, and was advanced 
to the rank of Commander on 1 Dec. 1964. 

Looking to the future, she says she may stay with 
the Navy or practice hospital pharmacy in Oakland, 
California. 

"I have already passed the California State Board 
of Pharmacy examination," she reports. 

Commander Keating is not the only member of 
her family in the service. One brother, TSgt. John F. 



Keating, is stationed with the Air Force at Yokota, 
Japan. 

Does Commander Keating think other women 
should consider serving with the Navy? 

"A career in the Navy," she claims, "can be a 
very exciting and rewarding experience but should 
not be undertaken by any individual who lacks a 
real desire to serve her country." 

ANNIVERSARY GREETINGS 
TO NURSE CORPS OFFICERS 

On this memorable occasion, the fifty-seventh an- 
niversary of the Navy Nurse Corps, I welcome the 
opportunity to extend greetings and best wishes. 
Despite the stress and strain of daily activities, may 
this special day bring a measure of true satisfaction 
to each of you. 

Significantly, this year commemorates the 20th 
anniversary of the cessation of World War II. It 
seems appropriate that we dedicate our anniversary 
to the Nurse Corps officers who served in the Corps 
during the period 7 December 1941 through the 
date of the truce, September, 1945. I know that 
you will join me in expressing our tribute and 
appreciation to all the 11,500 nurses who served 
during that crucial war era. 

History has recorded the deeds, heroism, and per- 
sonal sacrifices of these nurses. They brought expert 
nursing care, comfort and cheer to thousands of pa- 
tients at home, overseas, in the air, and aboard ship. . 
Individually, and as a Corps, they served over and 
beyond all expectation. Day by day, month by 
month, and year by. year they adapted to changing 
medical practice and brought improved methods of 
administration and nursing to their units. All deserve 
our thanks for the progressive advancements made 
during their tenure. 

Additionally, these nurses shared in the hardships 
and tragedies brought about by war. The entire 
Corps expressed sympathy and personal concern for 
their courageous nurse colleagues who were captured 
on Guam and the Philippine Islands and who be- 
came prisoners of war. The esprit de corps was again 
evident, however, as we rejoiced with the news of 
their release. 

In retrospect, the members of the Nurse Corps re- 
joiced in the triumphs and honors accorded their fel- 
low officers. There was expressed pride in the knowl- 
edge that nurses were aboard three hospital ships of 



28 



U.S. NAVY MEDICAL NEWS LETTER 



the Third Fleet as the surrender was signed on the 
USS MISSOURI in Tokyo Bay, September, 1945. 
Soon thereafter, honors and commendations were 
awarded to nurses for their outstanding performances. 
The Distinguished Service Medal was awarded to 
CAPT Sue Dauser, NC USN (ret), Director of the 
Navy Nurse Corps, CDR Ann A. Bernaitus, NC 
USN (ret) received the Legion of Merit. Fourteen 
Nurses received the Bronze Star Medal. CAPT C. 
Edwina Todd, NC USN, Chief of Nursing Service 
at the U. S. Naval Hospital, Portsmouth, Virginia 
was a recipient of the Bronze Star Medal. Over 250 
additional nurses received commendations. 

We all realize that these achievements and events 
represent only a sampling of the notable efforts of 
the Nurse Corps officers who served during World 
War II. We are profoundly proud of them and salute 
these officers on the fifty-seventh anniversary of the 
Navy Nurse Corps. 

I am equally proud of the members of the Corps 
today. Many' of you entered the ranks in recent 
years. You serve with nurses who entered the Navy 
prior to Pearl Harbor, as well as with those who 
volunteered during World War II. All of you con- 
tinue to serve with dedication and purpose that are 
traditional ideals of the Naval Service. You have 
an illustrious heritage and are worthy successors. 

My warmest personal regards and congratulations 
to each. 



HAPPY ANNIVERSARY 

S/ Ruth A. Erickson 

CAPT, NC, USN 

Director, Navy Nurse Corps 

TO THE OFFICERS OF THE 
NAVY NURSE CORPS 

On the occasion of your Corps' fifty-seventh an- 
niversary, I extend my sincere congratulations to all 
of you. 

Since the establishment of the Navy Nurse Corps 
on May 13, 1908, your record of achievement and 
professional progress has been viewed with pride by 
all members of the Medical Department. Your devo- 
tion to duty, proficiency, and ability to adapt to 
changing needs of service and professional trends 
has contributed immeasurably in the accomplish- 
ment of our mission. 

May you continue to serve so capably and dili- 
gently in the challenging decade ahead and may the 
succeeding years be rewarding ones for you. 



R. B. BROWN 

Rear Admiral, MC, USN 

Surgeon General 



* 

* 



U.S. NAVY MEDICAL NEWS LETTER 



29 



DEPARTMENT OF THE NAVY 

U. S. NAVAL MEDICAL SCHOOL 

NATIONAL NAVAL MEDICAL CENTER 

BETHESDA, MARYLAND 20014 

OFFICIAL BUSINESS 
PERMIT NO. 1048 



POSTAGE AND FEES PAID 
NAVY DEPARTMENT 



CAPT CARL T-. PRUITT MC tISM 
ASS'l, FOR MED. & ALLIED SCIENCES 
DCO-- a OeU', OP 07E 
THE PENTAGON, 
•ASHINGTON, D.C. 



30 



U.S. NAVY MEDICAL NEWS LETTER